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Relative reproductive success and failure are the ultimate determinants of Darwinian fitness. As such, reproductive traits and variations therein have an immediate and considerable impact on the evolutionary trajectory of lineages. Historically, significant attention has been paid to the ecological and evolutionary processes (ultimate factors) that shape the diversity and canalization of reproductive traits within groups to better our understanding of organismal diversity and population or species resilience. In contrast, the physiological systems that mediate variation within and among species (i.e., the proximate factors) in reproductive traits remain a significant black box. To date, there is comparatively little information about how proximate mechanisms constrain or promote evolutionary potential in reproductive traits. In this mini-review, we focus on litter size in Eutherian mammals as a trait with relatively well-defined diversity (litter sizes are well-described both within and across species) and for which some genetic determinants have been identified. We discuss both the ultimate and potential proximate determinants of litter size with special attention to the breadth of physiological traits that may act as "toggle" switches for evolution of litter size. We close with a brief discussion of the role that physiological plasticity may play in the evolution of litter size and lay out several forward-looking areas for future research., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Integrative and Comparative Biology.)

Background: The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. The authors aimed to evaluate outcomes of the VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction., Methods: The authors conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January of 2001 and March of 2021. Our primary outcome measure included recipient and donor surgical-site occurrences (SSOs)., Results: The authors identified a total of 546 patients (55% women) with a mean age of 58 years and mean body mass index of 27 kg/m 2 . Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient SSOs occurred in 38% of patients, and donor SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients, and bulge developed in 6.4% of patients. The Cox proportional hazards regression model for hernia occurrence identified age, body mass index, tobacco use (hazard ratio, 2.03; 95% CI, 1.02 to 4.04), and use as an extended VRAM flap (hazard ratio, 2.13; 95% CI, 1.04 to 4.36). The use of mesh or component separation were not independent protective factors for hernia occurrence., Conclusions: The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor-site hernia occurrence., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Abdominal wall reconstruction (AWR) is a treatment option for structural defects of the abdominal wall. The most frequently cited publications related to AWR have not been quantitatively or qualitatively assessed. This bibliometric analysis characterizes and assesses the most frequently cited AWR publications, to identify trends, gaps, and guide future efforts for the international research community., Methods: The 100 most cited publications in AWR were identified on Web of Science, across all available journal years (from May 1964 to December 2023). Study details, including the citation count, main content focus, and outcome measures, were extracted and tabulated from each publication. Oxford Centre for Evidence-Based Medicine levels of evidence (LOE) of each study were also assessed., Results: The 100 most cited publications in AWR were cited by a total of 9674 publications. Citations per publication ranged from 43 to 414 (mean 96.7 ± 52.48). Most publications were LOE 3 (n = 60), representative of the large number of retrospective cohort studies. The number of publications for LOE 5, 4, 3, 2, and 1 was 21, 2, 60, 2, and 12, respectively. The main content focus was surgical technique in 44 publications followed by outcomes in 38 publications. Patient-reported outcome measures were used in 3 publications, and no publications reported validated esthetic outcome measures., Conclusions: Overall, 3 was the LOE for most frequently cited AWR publications, with more publications below LOE 3 than above LOE 3. Validated outcome measures and patient-reported outcome measures were infrequently incorporated in the studies evaluated., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The skin ischemia and necrosis (SKIN) score was introduced to standardize the assessment of mastectomy skin flap necrosis (MSFN) severity and the need for reoperation. The authors evaluated the association between the SKIN score and the long-term postoperative outcomes of MSFN after mastectomy and immediate breast reconstruction., Methods: The authors conducted a retrospective cohort study of consecutive patients who developed MSFN after mastectomy and immediate breast reconstruction from January of 2001 to January of 2021. The primary outcome was breast-related complications after MSFN. Secondary outcomes were 30-day readmission, operating room (OR) débridement, and reoperation. Study outcomes were correlated with the SKIN composite score., Results: The authors identified 299 reconstructions in 273 consecutive patients with mean follow-up time of 111.8 ± 3.9 months. Most patients had a composite SKIN score of B2 (25.0%, n = 13), followed by D2 (17.3%) and C2 (15.4%). We found no significant difference in rates of OR débridement ( P = 0.347), 30-day readmission ( P = 0.167), any complication ( P = 0.492), or reoperation for a complication ( P = 0.189) based on the SKIN composite score. The composite skin score was a poor predictor of reoperation, with an area under the curve of 0.56. A subgroup analysis in patients who underwent implant-based reconstruction revealed no difference in rates of OR débridement ( P = 0.986), 30-day readmission ( P = 0.530), any complication ( P = 0.492), or reoperation for a complication ( P = 0.655) based on the SKIN composite score., Conclusions: The SKIN score was a poor predictor for postoperative MSFN outcomes and reoperation. An individualized risk-assessment tool that incorporates the anatomic appearance of the breast, imaging data, and patient-level risk factors is needed., Clinical Question/level of Evidence: Risk, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: It is not clear whether mesh-reinforced anterior component separation (CS) for abdominal wall reconstruction (AWR) results in better outcomes than mesh-reinforced primary fascial closure (PFC) without CS, particularly when acellular dermal matrix is used. The authors compared outcomes of CS versus PFC repair in AWR procedures aiming to determine whether CS results in better outcomes., Methods: This retrospective study of prospectively collected data included 461 patients who underwent AWR with acellular dermal matrix during a 10-year period at an academic cancer center. The primary endpoint was hernia recurrence; the secondary outcome was surgical-site occurrence (SSO)., Results: A total of 322 patients (69.9%) who underwent mesh-reinforced AWR with CS (AWR-CS) and 139 (30.1%) who underwent AWR with PFC (AWR-PFC) without CS were compared. AWR-PFC repairs had a higher hernia recurrence rate than AWR-CS repairs (10.8% versus 5.3%; P = 0.002) but similar overall complication (28.8% versus 31.4%; P = 0.580) and SSO (18.7% versus 25.2%; P = 0.132) rates. CS repairs experienced significantly higher wound separation (17.7% versus 7.9%; P = 0.007), fat necrosis (8.7% versus 2.9%; P = 0.027), and seroma (5.6% versus 1.4%; P = 0.047) rates than PFC repairs. The best cutoff with respect to hernia recurrence was 7.1 cm of abdominal defect width., Conclusion: AWR-CS repair resulted in a lower hernia recurrence rate than AWR-PFC but, despite the additional surgery, had similar SSO rates on long-term follow-up., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Postmastectomy radiotherapy (PMRT) is associated with altered cosmetic outcomes and higher complication rates in implant-based breast reconstruction (IBR). Conventional wisdom suggests that muscle coverage is somewhat protective against PMRT-related complications. In this study, the authors compared surgical outcomes in patients who underwent two-stage prepectoral versus subpectoral IBR in the setting of PMRT., Methods: The authors performed a retrospective cohort study of patients who underwent mastectomy and PMRT with two-stage IBR from 2016 to 2019. The primary outcome was breast-related complications, including device infection; the secondary outcome was device explantation., Results: The authors identified 179 reconstructions (101 prepectoral and 78 subpectoral) in 172 patients with a mean follow-up time of 39.7 ± 14.4 months. There were no differences between the prepectoral and subpectoral reconstructions in rates of breast-related complications (26.7% and 21.8%, respectively; P = 0.274), device infection (18.8% and 15.4%, respectively; P = 0.307), skin flap necrosis (5.0% and 1.3%, respectively; P = 0.232), or device explantation (20.8% and 14.1%, respectively; P = 0.117). In adjusted models, compared with prepectoral device placement, subpectoral device placement was not associated with a lower risk of breast-related complications [hazard ratio (HR), 0.75; 95% confidence interval (CI), 0.41 to 1.36], device infection (HR, 0.73; 95% CI, 0.35 to 1.49), or device explantation (HR, 0.58; 95% CI, 0.28 to 1.19)., Conclusions: Device placement plane was not predictive of complication rates in IBR in the setting of PMRT. Two-stage prepectoral IBR provides safe long-term outcomes with acceptable postoperative complication rates comparable to those with subpectoral IBR, even in the setting of PMRT., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction., Patients and Methods: We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort., Results: We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011)., Conclusion: Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients., (© 2023. Society of Surgical Oncology.)

Background: While many studies evaluated outcomes of abdominal wall reconstruction with biologic mesh, long-term data is lacking. In this study, we sought to analyze the outcomes of complex AWR with biologic mesh in a robust cohort of patients with a mean follow up of 8 years., Methods: We conducted a longitudinal study of AWR patients from 2005 to 2019. Hernia recurrence was the primary outcome, and surgical site occurrence was the secondary outcome. Predictive/protective factors were identified using a Cox proportional hazards regression models., Results: We identified 109 consecutive patients who met the inclusion criteria. Patient's mean (± SD) age was 57.5 ± 11.8 years, mean body mass index was 30.7 ± 7.2 kg/m 2 , and mean follow-up time was 96.2 ± 15.9 months. Fifty-six percent had clean defects, 34% had clean-contaminated defects, and 10% had contaminated/infected defects. Patients had a mean defect size of 261 ± 199.6 cm 2 and mean mesh size of 391.3 ± 160.2 cm 2 . Nineteen patients (17.4%) developed HR at the final follow-up date. Obesity was independently associated with a four-fold higher risk of HR (hazard ratio, 3.98; 95%CI, 1.34 to 14.60, p = 0.02). SSOs were identified in 24.8% of patients. A prior hernia repair was associated with a three-fold higher risk of SSOs (Odds ratio, 3.13; 95%CI, 1.10 to 8.94, p = 0.03). No patient developed mesh infection., Conclusion: These longitudinal data demonstrate that complex AWR with biologic mesh provides long-term durable outcomes with acceptable HR and SSO rates despite high contamination levels, patients complexity, and large defect size., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Summary: Thigh-based flaps are increasingly popular options for autologous breast reconstruction in the setting of abdominal donor-site inadequacy, previous surgery, or patient preference, but the volume and skin associated with these flaps are often lacking relative to the abdomen. An individualized, shared decision-making approach to donor-site selection was adopted based on body shape, surgical history, lifestyle, reconstructive needs, and patient expectations. Different thigh-based flaps combined in stacked, bipedicled, or conjoined configurations were selected to maximize efficient use of available soft-tissue skin and volume while optimizing donor-site aesthetics. A total of 23 thigh-based stacked, bipedicled, or conjoined profunda artery perforator (PAP), lateral thigh perforator (LTP), or gracilis musculocutaneous flap components were used in six patients. Configurations included bilateral stacked PAP and LTP flaps, bipedicled posterolateral thigh flaps based on the LTP and PAP (L-PAP), and bipedicled thigh flaps based on the gracilis and PAP pedicles. Most anastomoses were performed to the antegrade and retrograde internal mammary vessels; intraflap anastomoses were performed in one case. There were no partial or total flap losses. There was one donor-site seroma. Design of stacked, bipedicled, and conjoined thigh-based flaps using multiple conventional flap components allows for tailored approaches to donor-site utilization based on individual body shape in selected patients. Bipedicled design with the L-PAP flap represents one strategy in appropriate cases to overcome skin and volume deficiencies while facilitating coning and projection., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Despite improvements in prosthesis design and surgical techniques, periprosthetic infection and explantation rates following implant-based reconstruction (IBR) remain relatively high. Artificial intelligence is an extremely powerful predictive tool that involves machine learning (ML) algorithms. We sought to develop, validate, and evaluate the use of ML algorithms to predict complications of IBR., Methods: A comprehensive review of patients who underwent IBR from January of 2018 to December of 2019 was conducted. Nine supervised ML algorithms were developed to predict periprosthetic infection and explantation. Patient data were randomly divided into training (80%) and testing (20%) sets., Results: The authors identified 481 patients (694 reconstructions) with a mean ± SD age of 50.0 ± 11.5 years, mean ± SD body mass index of 26.7 ± 4.8 kg/m 2 , and median follow-up time of 16.1 months (range, 11.9 to 3.2 months). Periprosthetic infection developed in 113 of the reconstructions (16.3%), and explantation was required with 82 (11.8%) of them. ML demonstrated good discriminatory performance in predicting periprosthetic infection and explantation (area under the receiver operating characteristic curve, 0.73 and 0.78, respectively), and identified nine and 12 significant predictors of periprosthetic infection and explantation, respectively., Conclusions: ML algorithms trained using readily available perioperative clinical data accurately predict periprosthetic infection and explantation following IBR. The authors' findings support incorporating ML models into perioperative assessment of patients undergoing IBR to provide data-driven, patient-specific risk assessment to aid individualized patient counseling, shared decision-making, and presurgical optimization., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Mastectomy skin flap necrosis (MSFN) is a common complication following mastectomy that causes significant distress to patients and physicians and also compromises oncologic, surgical, and quality-of-life outcomes., Objectives: We sought to investigate the long-term outcomes of MSFN following implant-based reconstruction (IBR) and determine the rates and predictors of post-MSFN complications., Methods: This was a 20-year analysis of consecutive adult (>18 years) patients who developed MSFN following mastectomy and IBR from January 2001 to January 2021. Multivariable analyses were performed to identify factors associated with post-MSFN complications., Results: We identified 148 reconstructions, with a mean follow-up time of 86.6 ± 52.9 months. The mean time from reconstruction to MSFN was 13.3 ± 10.4 days, and most cases (n = 84, 56.8%) were full-thickness injuries. Most cases (63.5%) were severe, 14.9% were moderate, and 21.6% were mild. Forty-six percent (n = 68) developed a breast-related complication, with infection being the most common (24%). An independent predictor of overall complications was longer time from reconstruction to MSFN (odds ratio [OR], 1.66; P = .040). Aging was an independent predictor of overall complications (OR, 1.86; P = .038); infection (OR, 1.72; P = .005); and dehiscence (OR, 6.18; P = .037). Independent predictors of dehiscence were longer interval from reconstruction to MSFN (OR, 3.23; P = .018) and larger expander/implant size (OR, 1.49; P = .024). Independent predictors of explantation were larger expander/implant size (OR, 1.20; P = .006) and nipple-sparing mastectomy (OR, 5.61; P = .005)., Conclusions: MSFN is associated with high risk of complications following IBR. Awareness of the timing and severity of MSFN and the predictors of post-MSFN complications is crucial for guiding evidence-based decision-making and improving outcomes., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Abdominal wall reconstruction (AWR) is one of the most commonly performed procedures, yet large comparative studies comparing outcomes of AWR using bovine acellular dermal matrix (BADM) and porcine acellular dermal matrix (PADM) are lacking., Methods: In this retrospective cohort study of patients who underwent AWR from March of 2005 to June of 2019, the primary comparative outcome measure was hernia recurrence with BADM versus PADM. The secondary outcome was the incidence of surgical-site occurrence (SSO) and surgical-site infection. A propensity score matching approach was applied to compare the clinical outcomes between the two study groups., Results: The authors identified 725 patients who underwent AWR using BADM (50.5%) or PADM (49.5%). Their mean ± SD age was 59.8 ± 11.5 years, mean body mass index was 31.4 ± 6.7 kg/m 2 , and mean follow-up time was 42 ± 29 months. With propensity score matching, 219 matched pairs were identified. Hernia recurrence rates in BADM (11.4%) and PADM (13.7%) groups did not differ significantly ( P = 0.793). SSO (26.5% versus 29.2%; P = 0.518) and SSI (13.2% versus 11%; P = 0.456) rates did not differ significantly in the PADM and BADM groups, respectively. Conditional logistic regression model and marginal Cox proportional hazards regression model determined that type of acellular dermal matrix was not significantly associated with SSOs (adjusted OR, 1.11; 95% CI, 0.74 to 1.70; P = 0.589) or hernia recurrence (adjusted hazard ratio, 0.85; 95% CI, 0.50 to 1.42; P = 0.52)., Conclusions: Both BADMs and PADMs provide durable, long-term outcomes. The hernia recurrence and postoperative surgical complication rates were not significantly different between BADM and PADM., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Opinion regarding the optimal plane for prosthetic device placement in breast reconstruction patients has evolved. The purpose of this study was to assess the differences in complication rates and patient satisfaction between patients who underwent prepectoral and subpectoral implant-based breast reconstruction (IBR)., Methods: The authors conducted a retrospective cohort study of patients who underwent two-stage IBR at their institution from 2018 to 2019. Surgical and patient-reported outcomes were compared between patients who received a prepectoral versus a subpectoral tissue expander., Results: A total of 694 reconstructions in 481 patients were identified (83% prepectoral, 17% subpectoral). The mean body mass index was higher in the prepectoral group (27 versus 25 kg/m 2 , P = 0.001), whereas postoperative radiotherapy was more common in the subpectoral group (26% versus 14%, P = 0.001). The overall complication rate was very similar, with 29.3% in the prepectoral and 28.9% in the subpectoral group ( P = 0.887). Rates of individual complications were also similar between the two groups. A multiple-frailty model showed that device location was not associated with overall complications, infection, major complications, or device explantation. Mean scores for Satisfaction with the Breast, Psychosocial Well-Being, and Sexual Well-Being were similar between the two groups. Median time to permanent implant exchange was significantly longer in the subpectoral group (200 versus 150 days, P < 0.001)., Conclusion: Prepectoral breast reconstruction results in similar surgical outcomes and patient satisfaction compared with subpectoral IBR., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The impact of obesity on outcomes of prepectoral vs subpectoral implant-based reconstruction (IBR) is not well-established., Objectives: The goal of this study was to assess the surgical and patient-reported outcomes of prepectoral vs subpectoral IBR. The authors hypothesized that obese patients would have similar outcomes regardless of device plane., Methods: We conducted a retrospective review of obese patients who underwent 2-stage IBR from January 2017 to December 2019. The primary endpoint was the occurrence of any breast-related complication; the secondary endpoint was device explantation., Results: The authors identified a total of 284 reconstructions (184 prepectoral, 100 subpectoral) in 209 patients. Subpectoral reconstruction demonstrated higher rates of overall complications (50% vs 37%, P = .047) and device explantation (25% vs 12.5%, P = .008) than prepectoral reconstruction. In multivariable regression, subpectoral reconstruction was associated with higher risk of infection (hazard ratio [HR], 1.65; P = .022) and device explantation (HR, 1.97; P = .034). Subgroup analyses demonstrated significantly higher rates of complications and explantation in the subpectoral group in those with a body mass index (BMI) ≥ 35 and BMI ≥40. The authors found no significant differences in mean scores for satisfaction with the breast (41.57 ± 13.19 vs 45.50 ± 11.91, P = .469), psychosocial well-being (39.43 ± 11.23 vs 39.30 ± 12.49, P = .915), and sexual well-being (17.17 ± 7.83 vs 17.0 ± 9.03, P = .931) between subpectoral and prepectoral reconstruction., Conclusions: Prepectoral reconstruction was associated with significantly decreased overall complications, infections, and device explantation in obese patients compared with subpectoral reconstruction. Prepectoral reconstruction provides superior outcomes to subpectoral reconstruction with comparable patient-reported outcomes., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients., Study Design: This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies., Results: We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021)., Conclusions: Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To develop, validate, and evaluate ML algorithms for predicting MSFN., Background: MSFN is a devastating complication that causes significant distress to patients and physicians by prolonging recovery time, compromising surgical outcomes, and delaying adjuvant therapy., Methods: We conducted comprehensive review of all consecutive patients who underwent mastectomy and immediate implant-based reconstruction from January 2018 to December 2019. Nine supervised ML algorithms were developed to predict MSFN. Patient data were partitioned into training (80%) and testing (20%) sets., Results: We identified 694 mastectomies with immediate implant-based reconstruction in 481 patients. The patients had a mean age of 50 ± 11.5 years, years, a mean body mass index of 26.7 ± 4.8 kg/m 2 , and a median follow-up time of 16.1 (range, 11.9-23.2) months. MSFN developed in 6% (n = 40) of patients. The random forest model demonstrated the best discriminatory performance (area under curve, 0.70), achieved a mean accuracy of 89% (95% confidence interval, 83-94), and identified 10 predictors of MSFN. Decision curve analysis demonstrated that ML models have a superior net benefit regardless of the probability threshold. Higher body mass index, older age, hypertension, subpectoral device placement, nipple-sparing mastectomy, axillary nodal dissection, and no acellular dermal matrix use were all independently associated with a higher risk of MSFN., Conclusions: ML algorithms trained on readily available perioperative clinical data can accurately predict the occurrence of MSFN and aid in individualized patient counseling, preoperative optimization, and surgical planning to reduce the risk of this devastating complication., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: While many factors have been correlated with lesser outcomes in abdominal wall reconstruction (AWR), the impact of surgeon experience has yet to be elucidated. We sought to evaluate the effect of cumulative surgeon experience on long-term complex AWR outcomes., Methods: We conducted a comprehensive review of all consecutive patients who underwent AWR using biologic mesh for the repair of ventral hernias or tumor resection defects from March 2005 to June 2019. The primary outcome measure was hernia recurrence (HR). Secondary outcomes were surgical site occurrences (SSOs) and surgical site infections (SSIs). Patients were a priori categorized into the following groups according to the cumulative number of hernia repairs performed by their surgeons: low (< 50), moderate experience (50-100), and high (> 100) experience., Results: We identified 60 surgeons and 650 consecutive patients (62% women) who met our inclusion criteria. In adjusted models, AWR performed by surgeons with high experience was associated with a fourfold lower risk of HR (hazard ratio, 0.28; 95% confidence interval, 0.08 to 0.87), but the odds of surgical site occurrences (odds ratio, 0.72, 95% confidence interval, 0.34 to 1.52) and surgical site infections (odds ratio, 0.89, 95% confidence interval, 0.26 to 2.86) did not differ significantly in the high-experience group., Conclusions: High surgical experience, defined as > 100 cumulative hernia repairs, is predictive for markedly lower HR rates in complex AWR. These findings have potential implications for preoperative risk assessment, patient-centered surgeon selection, regulatory oversight, specific referral patterns, designations of centers of excellence, and individual provider or trainee quality improvement., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background:  Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction., Methods:  We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018., Results:  We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p  = 0.45), any breast-related complications (18 and 21%, respectively, p  = 0.75), or any major breast-related complications (13 and10%, respectively, p  = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group ( p  = 0.18)., Conclusion:  Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Outcomes studies for abdominal wall reconstruction (AWR) in the setting of previous oncologic extirpation are lacking. We sought to evaluate long-term outcomes of AWR using acellular dermal matrix (ADM) after extirpative resection, compare them to primary herniorrhaphy, and report the rates and predictors of postoperative complications., Methods: We conducted a retrospective cohort study of patients who underwent AWR after oncologic resection from March 2005 to June 2019 at a tertiary cancer center. The primary outcome was hernia recurrence (HR). Secondary outcomes included surgical site occurrences (SSOs), surgical site infection (SSIs), length of hospital stay (LOS), reoperation, and 30-day readmission., Results: Of 720 consecutive patients who underwent AWR during the study period, 194 (26.9%) underwent AWR following resection of abdominal wall tumors. In adjusted analyses, patients who had AWR after extirpative resection were more likely to have longer LOS (β, 2.57; 95%CI, 1.27 to 3.86, p < 0.001) than those with primary herniorrhaphy, but the risk of HR, SSO, SSI, 30-day readmission, and reoperation did not differ significantly. In the extirpative cohort, obesity (Hazard ratio, 6.48; p = 0.003), and bridged repair (Hazard ratio, 3.50; p = 0.004) were predictors of HR. Radiotherapy (OR, 2.23; p = 0.017) and diabetes mellites (OR, 3.70; p = 0.005) were predictors of SSOs. Defect width (OR, 2.30; p < 0.001) and mesh length (OR, 3.32; p = 0.046) were predictors of SSIs. Concomitant intra-abdominal surgery for active disease was not associated with worse outcomes., Conclusions: AWR with ADM following extirpative resection demonstrated outcomes comparable with primary herniorrhaphy. Preoperative risk assessment and optimization are imperative for improving outcomes., (© 2023. Society of Surgical Oncology.)

Interest in the use of artificial intelligence (AI) and machine learning (ML) in medicine has grown exponentially over the last few years. With its ability to enhance speed, precision, and efficiency, AI has immense potential, especially in the field of surgery. This article aims to provide a comprehensive literature review of artificial intelligence as it applies to surgery and discuss practical examples, current applications, and challenges to the adoption of this technology. Furthermore, we elaborate on the utility of natural language processing and computer vision in improving surgical outcomes, research, and patient care.

Background: Prepectoral implant-based breast reconstruction (IBR) has become the standard of care for many reconstructive surgeons and is often supplemented with coverage using acellular dermal matrix (ADM). However, more clinical data examining the use of ADM in breast reconstruction are needed. The current study compares complications and patient-reported outcomes (PROs) among three different types of ADM used in IBR., Methods: The authors performed a retrospective review of consecutive patients who underwent immediate prepectoral IBR from January of 2018 through December of 2019. Surgical outcomes and PROs (using the BREAST-Q) were compared among the AlloDerm, SurgiMend, and Dermacell ADMs., Results: Overall, 557 breasts (383 patients) were included (78.6% AlloDerm, 14% SurgiMend, 7.4% Dermacell). Patients in the Dermacell group were older ( P = 0.001) and more likely to have diabetes ( P = 0.001) compared with AlloDerm and SurgiMend patients. Other patient characteristics were similar among the three groups. The overall complication rate was equivalent among the three ADM groups (AlloDerm 27% vs SurgiMend 33% vs Dermacell 39%; P = 0.209). Multivariable frailty models demonstrated that the type of ADM was not significantly associated with overall complications, infection, major complications, or device explantation. BREAST-Q satisfaction with breasts, psychosocial well-being, and sexual well-being were also similar among the three ADM groups ( P = 0.109, P = 0.439, P = 0.152, respectively)., Conclusions: Three of the most commonly used ADMs in the United States have similar surgical outcomes and PROs when used for prepectoral IBR. No significant differences in infection, overall complications, or device removal rates were identified among AlloDerm, SurgiMend, and Dermacell., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objective: To determine if global budget revenue (GBR) models incent the centralization of complex surgical care., Summary Background: In 2014, Maryland initiated a statewide GBR model. While prior research has shown improvements in cost and outcomes for surgical care post-GBR implementation, the mechanism remains unclear., Methods: Utilizing state inpatient databases, we compared the proportion of adults undergoing elective complex surgeries (gastrectomy, pneumonectomy/lobectomy, proctectomies, and hip/knee revision) at high-concentration hospitals (HCHs) in Maryland and control states. Annual concentration, per procedure, was defined as hospital volume divided by state volume. HCHs were defined as hospitals with a concentration at least at the 75 th percentile in 2010. We estimated the difference-in-differences (DiD) of the probability of patients undergoing surgery at HCHs before and after GBR implementation., Findings: Our sample included 122,882 surgeries. Following GBR implementation, all procedures were increasingly performed at HCHs in Maryland. States satisfied the parallel trends assumption for the centralization of gastrectomy and pneumonectomy/lobectomy. Post-GBR, patients were more likely to undergo gastrectomy (DiD: 5.5 p.p., 95% CI [2.2, 8.8]) and pneumonectomy/lobectomy (DiD: 12.4 p.p., 95% CI [10.0, 14.8]) at an HCH in Maryland compared with control states. For our hip/knee revision analyses, we assumed persistent counterfactuals and noted a positive DiD post-GBR implementation (DiD: 4.8 p.p., 95% CI [1.3, 8.2]). No conclusion could be drawn for proctectomy due to different pre-GBR trends., Conclusions: GBR implementation is associated with increased centralization for certain complex surgeries. Future research is needed to explore the impact of centralization on patient experience and access., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

We compared the surgical skills and outcomes of microsurgical fellows who completed an independent versus integrated plastic surgery residency., Methods: We reviewed outcomes of abdominal wall reconstructions performed autonomously by microsurgical fellows at our institution from March 2005 to June 2019; outcome measures included hernia recurrence, surgical site occurrence, surgical site infection, length of hospital stay, unplanned return to the operating room, and 30-day readmission. The microsurgical skills were prospectively evaluated using the validated Structured Assessment of Microsurgical Skills at the start and end of the fellowship, in an animal laboratory model and clinical microsurgical cases. Multivariable hierarchical models were constructed to evaluate study outcomes., Results: We identified 44 fellows and 118 consecutive patients (52% women) who met our inclusion criteria. Independent fellows performed 55% (n = 65) of cases, and 45% were performed by integrated fellows. We found no significant difference in hernia recurrence, surgical site occurrences, surgical site infections, 30-day readmission, unplanned return to the operating room, or length of stay between the two groups in adjusted models. Although laboratory scores were similar between the groups, integrated fellows demonstrated higher initial clinical scores (42.0 ± 4.9 versus 37.7 ± 5.0, P = 0.04); however, the final clinical scores were similar (50.8 ± 6.0 versus 48.9 ± 5.2, P = 0.45)., Conclusions: Independent and integrated fellows demonstrated similar long-term patient outcomes. Although integrated fellows had better initial microsurgical skills, evaluation at the conclusion of fellowship revealed similar performance, indicating that fellowship training allows for further development of competent surgeons., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Implant-based reconstruction (IBR) is the most common method of breast reconstruction in the United States. Despite ongoing advancements, periprosthetic infection is a serious problem that often results in device explantation. The objective of this study was to evaluate the outcomes of third-attempt reconstruction in patients in whom secondary implant-based reconstruction failed because of infection., Methods: The authors performed a retrospective review of patients who underwent mastectomy followed by IBR from 2000 to 2019. The outcomes of patients in whom secondary IBR failed because of infection and who ultimately underwent third-attempt breast reconstruction were analyzed., Results: Of 6093 patients who underwent primary IBR, 13 patients had third-attempt breast reconstruction following infection-related explantation [median age, 52 years (interquartile range, 51 to 56 years); median body mass index, 23 kg/m 2 (interquartile range, 22 to 31 kg/m 2 ); median follow-up, 46 months (interquartile range, 16 to 62 months)]. Nine patients (70%) underwent IBR, two (15%) underwent IBR combined with pedicled latissimus dorsi flap, and two (15%) underwent abdominally based free tissue transfer. Third-attempt breast reconstruction was immediate in 46% of patients and delayed in 54%. The success rate was 78% in the IBR group, with a 23% complication rate. The success rate for autologous breast reconstruction was 100%, with one patient developing venous congestion necessitating return to the operating room., Conclusions: Third-attempt breast reconstruction following infection-associated failed secondary IBR is a safe and feasible option. Although the risk of failure is higher than that for primary implant-based reconstruction, a third attempt after secondary IBR infection had a surprisingly high 78% success rate., Clinical Question/level of Evidence: Risk, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Competing Interests: Disclosure:Neither author has any relevant financial interests or conflicts of interest to declare in relation to the content of this Discussion or of the associated article.

Background: Postmastectomy breast reconstruction in patients with a history of breast-conserving surgery (BCS) and radiotherapy is challenging, with a paucity of literature on the outcomes of different breast reconstructive techniques. The authors hypothesized that implant-based breast reconstruction (IBR) would be associated with higher complication rates compared to either IBR combined with latissimus dorsi (LD) or free flap breast reconstruction (FFBR)., Methods: The authors conducted a retrospective review of patients who underwent mastectomy with a history of BCS and radiotherapy between January of 2000 and March of 2016. Surgical and patient-reported outcomes (BREAST-Q) were compared between IBR versus IBR/LD versus FFBR., Results: The authors identified 9473 patients who underwent BCS and radiotherapy. Ninety-nine patients (105 reconstructions) met the authors' inclusion criteria, 29% ( n = 30) of whom underwent IBR, 26% ( n = 27) of whom underwent IBR/LD, and 46% ( n = 48) of whom underwent FFBR. The overall complication rate was not significantly different between the three groups (50% in IBR versus 41% in IBR/LD versus 44% in FFBR; P = 0.77), whereas reconstruction failures were significantly lower in the FFBR group (33% in IBR versus 19% in IBR/LD versus 0% in FFBR; P < 0.0001). The time between the receipt of radiotherapy and reconstruction was not a significant predictor of overall complications and reconstruction failure. No significant differences were identified between the three study cohorts in any of the three studied BREAST-Q domains., Conclusions: In patients with prior BCS and radiotherapy, FFBR was associated with lower probability of reconstruction failure compared to IBR but no significant difference in overall and major complication rates. The addition of LD flap to IBR did not translate into lower complication rates but may result in decreased reconstruction failures., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Artificial intelligence (AI) focuses on processing and interpreting complex information as well as identifying relationships and patterns among complex data. Artificial intelligence- and machine learning (ML)-driven predictions have shown promising potential in influencing real-time decisions and improving surgical outcomes by facilitating screening, diagnosis, risk assessment, preoperative planning, and shared decision-making. Fundamental understanding of the algorithms, as well as their development and interpretation, is essential for the evolution of AI in surgery. In this article, we provide surgeons with a fundamental understanding of AI-driven predictive models through an overview of common ML and deep learning algorithms, model development, performance metrics and interpretation. This would serve as a basis for understanding ML-based research, while fostering new ideas and innovations for furthering the reach of this emerging discipline.

Artificial intelligence (AI) has made steady in-roads into the healthcare scenario over the last decade. While widespread adoption into clinical practice remains elusive, the outreach of this discipline has progressed beyond the physician scientist, and different facets of this technology have been incorporated into the care of surgical patients. New AI applications are developing at rapid pace, and it is imperative that the general surgeon be aware of the broad utility of AI as applicable in his or her day-to-day practice, so that healthcare continues to remain up-to-date and evidence based. This review provides a broad account of the tip of the AI iceberg and highlights it potential for positively impacting surgical care.

The technology of artificial intelligence (AI) has made significant in-roads into the field of medicine over the last decade. With surgery being a discipline where repetition is the key to mastery, the scope of AI presents enormous potential for resident education through the analysis of technique and delivery of structured feedback for performance improvement. In an era marred by a raging pandemic that has decreased exposure and opportunity, AI offers an attractive solution towards improving operating room efficiency, safe patient care in the hands of supervised residents and can ultimately culminate in reduced health care costs. Through this article, we elucidate the current adoption of the artificial intelligence technology and its prospects for advancing surgical education.

Patient-reported outcomes (PROs) enable providers to identify differences in treatment effectiveness, postoperative recovery, quality of life, and patient satisfaction. By allowing a shift from disease-specific factors to the patient perspective, PROs provide a tailored patient-centric approach to shared decision-making. Artificial intelligence (AI) and machine learning (ML) techniques can facilitate such shared decision-making and improve patient outcomes by accurate prediction of PROs. This article aims to provide a comprehensive review of the use of AI and ML models in predicting PROs following surgery through an overview of common predictive algorithms and modeling techniques, as well as current applications and limitations in the surgical field.

Surgical complications pose significant challenges for surgeons, patients, and health care systems as they may result in patient distress, suboptimal outcomes, and higher health care costs. Artificial intelligence (AI)-driven models have revolutionized the field of surgery by accurately identifying patients at high risk of developing surgical complications and by overcoming several limitations associated with traditional statistics-based risk calculators. This article aims to provide an overview of AI in predicting surgical complications using common machine learning and deep learning algorithms and illustrates how this can be utilized to risk stratify patients preoperatively. This can form the basis for discussions on informed consent based on individualized patient factors in the future.

Deep learning (DL) is a subset of machine learning that is rapidly gaining traction in surgical fields. Its tremendous capacity for powerful data-driven problem-solving has generated computational breakthroughs in many realms, with the fields of medicine and surgery becoming increasingly prominent avenues. Through its multi-layer architecture of interconnected neural networks, DL enables feature extraction and pattern recognition of highly complex and large-volume data. Across various surgical specialties, DL is being applied to optimize both preoperative planning and intraoperative performance in new and innovative ways. Surgeons are now able to integrate deep learning tools into their practice to improve patient safety and outcomes. Through this review, we explore the applications of deep learning in surgery and related subspecialties with an aim to shed light on the practical utilization of this technology in the present and near future.

Muscle flaps must have a strong vascular network to support a large tissue volume and ensure successful engraftment. We developed porcine stomach musculofascial flap matrix (PDSF) comprising extracellular matrix (ECM) and intact vasculature. PDSF had a dominant vascular pedicle, microcirculatory vessels, a nerve network, well-retained 3-dimensional (3D) nanofibrous ECM structures, and no allo- or xenoantigenicity. In-depth proteomic analysis demonstrated that PDSF was composed of core matrisome proteins (e.g., collagens, glycoproteins, proteoglycans, and ECM regulators) that, as shown by Gene Ontology term enrichment analysis, are functionally related to musculofascial biological processes. Moreover, PDSF-human adipose-derived stem cell (hASC) synergy not only induced monocytes towards IL-10-producing M2 macrophage polarization through the enhancement of hASCs' paracrine effect but also promoted the proliferation and interconnection of both human skeletal muscle myoblasts (HSMMs) and human umbilical vein endothelial cells (HUVECs) in static triculture conditions. Furthermore, PDSF was successfully prevascularized through a dynamic perfusion coculture of hASCs and HUVECs, which integrated with PDSF and induced the maturation of vascular networks in vitro . In a xenotransplantation model, PDSF demonstrated myoconductive and immunomodulatory properties associated with the predominance of M2 macrophages and regulatory T cells. In a volumetric muscle loss (VML) model, prevascularized PDSF augmented neovascularization and constructive remodeling, which was characterized by the predominant infiltration of M2 macrophages and significant musculofascial tissue formation. These results indicate that hASCs' integration with PDSF enhances the cells' dual function in immunomodulation and angiogenesis. Owing in part to this PDSF-hASC synergy, our platform shows promise for vascularized muscle flap engineering for VML reconstruction., (© 2022 The Authors.)

Background: Autologous fat grafting is a useful tool in breast reconstruction. The authors have previously demonstrated a difference in the rate of processing adipose grafts in a randomized time and motion clinical trial. The purpose of this study was to compare clinical outcomes in commonly used grafting systems., Methods: Three methods to prepare adipose grafts were compared: a passive washing filtration system (Puregraft system), an active washing filtration system (Revolve system), and centrifugation (Coleman technique). Postoperative complications, rates of fat necrosis, revision procedures, and additional imaging were recorded., Results: Forty-six patients were included in the prospective, randomized study (15 active filtration, 15 passive filtration, and 16 centrifugation). Their mean age was 54 years and mean body mass index was 28.6 kg/m 2 . The mean length of follow-up was 16.9 ± 4 months. The overall complication rate was 12.1 percent. The probability of fat necrosis was no different between the groups (active filtration, 15 percent versus passive filtration, 14.3 percent] versus centrifugation, 8 percent; p = 0.72). Fat necrosis was highest in patients with breast conservation before grafting (60 percent; p = 0.011). There was no significant difference in contour irregularity (active filtration, 40 percent versus passive filtration, 38 percent versus centrifugation, 36 percent; p = 0.96) or additional grafting (active filtration, 40 percent versus passive filtration, 24 percent versus centrifugation, 32 percent; p = 0.34)., Conclusions: This is the first prospective, randomized study to compare clinical outcomes of adipose graft preparation. There was no significant difference in early complications, fat necrosis, or rates of additional grafting among the study groups. There was significantly higher risk of fat necrosis in patients with previous breast conservation treatment regardless of processing technique., Clinical Question/level of Evidence: Therapeutic, II., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: As more plastic surgery clinicians pursue advanced degrees and strive to become stronger physician-scientists, an objective understanding of how such degrees influence careers becomes important. We hypothesized that having a master's degree is associated with higher scholarly activity, research funding, academic progression, and leadership appointments., Methods: Accreditation Council for Graduate Medical Education-accredited integrated plastic surgery residency program Web sites were queried to create a data set of current academic plastic surgeons (APSs) and plastic surgery residents (PSRs). Scholarly metrics such as publications, citations, and H-indices were extracted from the Scopus database. National Institutes of Health and Plastic Surgery Foundation funding information was collected through their respective Web sites., Results: Our cohort comprised 799 APSs and 922 PSRs, of whom 8% and 7.4%, respectively, had at least one master's degree. Academic plastic surgeons with master's of public health degrees had a significantly higher median number of publications and citations than APSs without a master's of public health. There was no association between any master's degree and academic rank or being a department chairman or program director. Academic plastic surgeons with master of science degrees were more likely to receive National Institutes of Health grants. Among PSRs, master's of science graduates had a higher median number of publications. Other master's degrees did not significantly influence scholarly productivity or funding., Conclusions: Certain master's degrees had an impact on scholarly productivity, with no significant effect on academic rank or leadership positions. The value of master's degrees in programs focusing on healthcare management, leadership skills, and business acumen likely extends beyond the scope of this study., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Ventral hernia repair (VHR) is one of the most commonly performed procedures in the United States, but studies assessing the long-term outcomes of VHR using biologic mesh are scarce., Objective: We sought to determine the rates of hernia recurrence (HR) and surgical site occurrences (SSOs) in a large cohort of patients who underwent AWR with biologic mesh., Methods: We conducted a retrospective cohort study of patients who underwent AWR using either porcine ADM (PADM) or bovine ADM (BADM) from 2005 to 2019. We analyzed the full cohort and a subset of our population with minimum long-term follow-up (LTF) of 5 years. The primary outcome measure was HR. Secondary outcomes were SSOs., Results: We identified a total of 725 AWRs (49.5% PADM, 50.5% BADM). Mean age was 69 ± 11.5 years and mean body mass index was 31 ± 7 kg/m 2 . Forty-two percent of the defects were clean at the time of AWR, 44% were clean-contaminated, and 14% were contaminated/infected. Mean defect size was 180 ± 174 cm 2 , mean mesh size was 414 ± 203 cm 2 . Hernia recurred in 93 patients (13%), with cumulative HR rates of 4.9%, 13.5%, 17.3%, and 18.8% at 1, 3, 5, and 7 years, respectively. There were no differences in HR ( P = 0.83) and SSO ( P = 0.87) between the 2 mesh types. SSOs were identified in 27% of patients. In our LTF group (n = 162), the HR rate was 16%. Obesity, bridged repair, and concurrent stoma presence/creation were independent predictors of HR; component separation was protective against HR., Conclusions: Despite its use in complex AWR, ADM provides durable long-term outcomes with relatively low recurrence rates., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Telemedicine use during the COVID-19 pandemic among financially distressed patients with cancer, with respect to the determinants of adoption and patterns of utilization, has yet to be delineated. We sought to systematically characterize telemedicine utilization in financially distressed patients with cancer during the COVID-19 pandemic., Methods: We conducted a cross-sectional analysis of nationwide survey data assessing telemedicine use in patients with cancer during the COVID-19 pandemic collected by Patient Advocate Foundation (PAF) in December 2020. Patients were characterized as financially distressed by self-reporting limited financial resources to manage out-of-pocket costs, psychological distress, and/or adaptive coping behaviors. Primary study outcome was telemedicine utilization during the pandemic. Secondary outcomes were telemedicine utilization volume and modality preferences. Multivariable and Poisson regression analyses were used to identify factors associated with telemedicine use., Results: A convenience sample of 627 patients with cancer responded to the PAF survey. Telemedicine adoption during the pandemic was reported by 67% of patients, with most (63%) preferring video visits. Younger age (19-35 age compared to ≥ 75 age) (OR, 6.07; 95% CI, 1.47-25.1) and more comorbidities (≥ 3 comorbidities compared to cancer only) (OR, 1.79; 95% CI, 1.13-2.65) were factors associated with telemedicine adoption. Younger age (19-35 years) (incidence rate ratios [IRR], 1.78; 95% CI, 24-115%) and higher comorbidities (≥ 3) (IRR; 1.36; 95% CI, 20-55%) were factors associated with higher utilization volume. As area deprivation index increased by 10 units, the number of visits decreased by 3% (IRR 1.03, 95% CI, 1.03-1.05)., Conclusions: The rapid adoption of telemedicine may exacerbate existing inequities, particularly among vulnerable financially distressed patients with cancer. Policy-level interventions are needed for the equitable and efficient provision of this service., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The goal of this study was to assess whether adding a latissimus dorsi (LD) flap to a secondary implant-based reconstruction (IBR) improves outcomes following explantation of the primary device due to infection., Methods: We conducted a retrospective study of patients who underwent a second IBR with or without the addition of an LD flap during 2006-2019, following explantation due to infection. Surgical outcomes were collected and compared between reconstruction types., Results: A total of 6093 IBRs were identified during the study period. Of these, 109 underwent a second attempt at breast reconstruction with IBR alone (n = 86, 79%) or IBR/LD (n = 23, 21%) following explantation of an infected device. Rates of secondary device explantation due to a complication were similar between the two groups (26% in the IBR/LD group and 21% in the IBR group; P = 0.60). Among the patients who underwent prior radiotherapy, the IBR/LD group had lower rates of any complication (38% versus 56%; P = 0.43), infection (25% versus 44%; P = 0.39), and reconstruction failure (25% versus 44%; P = 0.39); however, differences were not statistically significant., Conclusion: Following a failed primary breast reconstruction due to infection, it may be appropriate to offer a secondary reconstruction. For patients with a history of radiotherapy, combining an LD flap with IBR may provide benefits over IBR alone. Although not statistically different, this outcome may have clinical significance, considering the magnitude of the effect, and may result in decreased complication rates and a higher chance of reconstructive success., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Infection is a dreaded complication of implant-based breast reconstruction. There is a paucity of literature on the outcomes of a secondary reconstruction after infected implant-based breast reconstruction explantation., Methods: The authors conducted a retrospective study of patients who underwent a second implant-based breast reconstruction following a failed infected device between January of 2006 and December of 2019. Surgical and patient-reported outcomes (BREAST-Q) were collected and analyzed., Results: A total of 6093 implant-based breast reconstructions were performed during the study period, 298 (5 percent) of which involved device removal because of infection. Eighty-three patients ultimately received 92 second-attempt breast implants. Thirty-six percent of cases developed at least one postoperative complication, with infection [23 breasts (25 percent)] being the most common. Compared with first-attempt implant-based breast reconstruction, we found significantly higher infection rates among second-attempt cases (9 percent and 21 percent, respectively; p = 0.0008). Patient-reported satisfaction with the breast and sexual well-being were lower after second-attempt than after first-attempt implant-based breast reconstruction ( p = 0.018 and p = 0.002, respectively) reported in the literature. Mean follow-up was 41 ± 35 months. If we exclude patients with prior radiation therapy and those who received device exchange, the success rate is 88 percent., Conclusions: It is reasonable to offer women second-attempt implant-based breast reconstruction after explantation because of infection. However, this patient population has a higher infection and explantation rate and lower patient-reported satisfaction than patients undergoing first-attempt implant-based breast reconstruction. Because of these increased surgical risks and elevated complication rates, patients must be given reasonable expectations during preoperative discussions and when providing informed consent for second-attempt implant-based breast reconstruction., Clinical Question/level of Evidence: Risk, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Competing Interests: Victor AgbafeConsulting or Advisory Role: Third Culture Capital Charles E. ButlerConsulting or Advisory Role: Tela Bio, Allergan, UpToDate, Becton, Dickinson and Company (BD), ECM Biosurgery Ernest HawkEmployment: MD Anderson Cancer CenterHonoraria: National Cancer Institute, AACR, Huntsman Cancer Institute, Mayo Clinic Cancer Center, Kansas University Medical Center, Roswell Park Cancer Institute, University of Nebraska Medical Center, University of New Mexico ECHO, Johns Hopkins Hospital, National Academies of Science Engineering Medicine, Virginia Commonwealth University, Albert Einstein Cancer Center, University of Alabama Birmingham, Rutgers Cancer Institute of New Jersey, UT Southwestern Simmons CCC, University of Wisconsin-Madison, Oregon Health & Science University (OHSU), Medical University of South CarolinaResearch Funding: NIH/NCI (Inst)Patents, Royalties, Other Intellectual Property: Jack Wiley & Sons Book chapterTravel, Accommodations, Expenses: NCI, Mayo Clinic Cancer Center, Johns Hopkins Hospital, National Academies of Science Engineering Medicine Anaeze C. Offodile IIOther Relationship: Blue Cross Blue Shield Association, National Academy of Medicine, Patient Advocate Foundation, Indiana University, Department of SurgeryNo other potential conflicts of interest were reported.

Background: Predatory journals have exploited the open access publishing model and are considered as a major threat to the integrity of scientific research. The goal of this study was to characterize predatory publishing practices in plastic surgery., Methods: To identify potentially predatory journals in the field of plastic surgery, the authors searched the Cabells' Predatory Reports and Beall's List using preidentified keywords. For presumed legitimate open access journals, the Directory of Open Access Journals (DOAJ) was queried. The characteristics of potentially predatory journals were compared to those of legitimate open access plastic surgery journals., Results: The authors identified a total of 25 plastic surgery-focused journals. Out of the 25 potentially predatory journals, only 15 journals had articles published within the last 5 years, with a mean number of articles of 33 ± 39 (range, 2 to 159 articles). The mean number of predatory violations according to Cabells' criteria was 6.8 ± 1.4 (range, 3 to 9). Using the DOAJ database, the authors identified a total of 24 plastic surgery-related journals. Compared to potentially predatory journals, journals from the DOAJ were more likely to be indexed in PubMed (0 versus 50 percent, respectively, p < 0.0001). Time to publication was significantly higher in journals from the DOAJ (17 ± 7 versus 4 ± 1 weeks; p = 0.006). Despite higher article processing charges in the DOAJ group, this difference was not statically significant ($1425 ± $717 versus $1071 ± $1060; p = 0.13)., Conclusions: Predatory journals are pervasive in the medical literature and plastic surgery is no exception. Plastic surgeons should practice due diligence when choosing a target journal for their articles. Journals with predatory practices should be distinguished from legitimate open access publication platforms., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable., Methods: The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups., Results: A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046)., Conclusions: Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Importance: Concern regarding surgical trainees' operative autonomy has increased in recent years, emphasizing patient safety and preparation for independent practice. Regarding abdominal wall reconstruction (AWR), long-term outcomes of fellow autonomy have yet to be delineated., Objectives: To evaluate the long-term outcomes of AWRs performed by fellows and compare them with those of AWRs performed by assistant, associate, and senior-level professors., Design, Setting, and Participants: This retrospective cohort study included patients who underwent AWR for ventral hernias or repair of tumor resection defects at a 710-bed tertiary cancer center between March 1, 2005, and June 30, 2019. The analysis was conducted between January 2020 and December 2021., Exposure: Academic rank of primary surgeon., Main Outcomes and Measures: The primary outcome was hernia recurrence. Secondary outcomes were surgical site occurrence, surgical site infection, length of hospital stay, unplanned return to the operating room, and 30-day readmission. Multivariable hierarchical models were constructed to identify predictive factors., Results: Of 810 consecutive patients, 720 (mean [SD] age, 59.8 [11.5] years; 375 female [52.1%]) met the inclusion criteria. Mean (SD) body mass index was 31.4 (6.7), and mean (SD) follow-up time was 42 (29) months. Assistant professors performed the most AWRs (276 [38.3%]), followed by associate professors (169 [23.5%]), senior-level professors (157 [21.8%]), and microsurgical fellows (118 [16.4%]). Compared with fellows and more junior surgeons, senior-level professors tended to operate on significantly older patients (mean [SD] age, 59.9 [10.9] years; P = .03), more patients with obesity (103 [65.6%]; P = .003), and patients with larger defects (247.9 [216.0] cm; P < .001), parastomal hernias (27 [17.2%]; P = .001), or rectus muscle violation (53 [33.8%]; P = .03). No significant differences were found for hernia recurrence, surgical site occurrence, surgical site infection, 30-day readmission rates, or length of stay among the fellows and assistant, associate, and senior-level professors in adjusted models. Compared with fellows, assistant professors (OR, 0.22; 95% CI, 0.08-0.64) and senior-level professors (OR, 0.20; 95% CI, 0.06-0.69) had lower rates of unplanned return to the operating room., Conclusions and Relevance: This cohort study provides evidence-based reassurance that providing fellows with autonomy in performing AWRs does not compromise long-term patient outcomes. These findings may incite efforts to increase appropriate surgical trainee autonomy, thereby empowering future generations of competent, independent surgeons.

Background: Despite advancements in abdominal wall reconstruction (AWR) techniques, hernia recurrences (HRs), surgical site occurrences (SSOs), and unplanned hospital readmissions persist. We sought to develop, validate, and evaluate machine learning (ML) algorithms for predicting complications after AWR., Methods: We conducted a comprehensive review of patients who underwent AWR from March 2005 to June 2019. Nine supervised ML algorithms were developed to preoperatively predict HR, SSOs, and 30-day readmission. Patient data were partitioned into training (80%) and testing (20%) sets., Results: We identified 725 patients (52% women), with a mean age of 60 ± 11.5 years, mean body mass index of 31 ± 7 kg/m2, and mean follow-up time of 42 ± 29 months. The HR rate was 12.8%, SSO rate was 30%, and 30-day readmission rate was 10.9%. ML models demonstrated good discriminatory performance for predicting HR (area under the receiver operating characteristic curve [AUC] 0.71), SSOs (AUC 0.75), and 30-day readmission (AUC 0.74). ML models achieved mean accuracy rates of 85% (95% CI 80% to 90%), 72% (95% CI 64% to 80%), and 84% (95% CI 77% to 90%) for predicting HR, SSOs, and 30-day readmission, respectively. ML identified and characterized 4 unique significant predictors of HR, 12 of SSOs, and 3 of 30-day readmission. Decision curve analysis demonstrated that ML models have a superior net benefit regardless of the probability threshold., Conclusions: ML algorithms trained on readily available preoperative clinical data accurately predicted complications of AWR. Our findings support incorporating ML models into the preoperative assessment of patients undergoing AWR to provide data-driven, patient-specific risk assessment., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Evaluate long-term outcomes of abdominal wall reconstruction (AWR) using xenogeneic mesh in patients with Centers for Disease Control and Prevention (CDC) class III/IV defects. We hypothesized that AWR with xenogeneic mesh results in acceptable outcomes., Background: Optimal mesh selection in AWR of CDC class III/IV defects is controversial. Outcomes using xenogeneic mesh are lacking., Methods: We conducted a retrospective cohort study of patients who underwent AWR using xenogeneic mesh in CDC class III/IV defects from March 2005 to June 2019. Primary outcome was hernia recurrence (HR). Secondary outcomes were surgical site occurrence (SSO) and surgical site infection (SSI)., Results: Of consecutive 725 AWRs, we identified 101 patients who met study criteria. Sixty-eight patients had class III defects, while 33 had class IV defects. Patients had a mean age of 61.3 ± 11.1 years, mean body mass index of 31.8 ± 7.3 kg/m 2 , and mean follow-up time of 41.9 ± 26.3 months. Patients had HR rate of 21%, SSO rate of 49%, and SSI rate of 24. Class IV defects were predictive of SSOs (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.11-7.42; P = 0.029) but not HR (hazard ratio, 1.60; 95% CI, 0.59-4.34; P = 0.355) or SSIs (OR, 2.62; 95% CI, 0.85-8.10; P = 0.094)., Conclusions: Patients with class IV defects have a higher risk of SSOs, but not HR or SSIs, compared with patients with class III defects. Despite the high level of defect contamination, AWR with xenogeneic mesh demonstrated acceptable HR, SSO, and SSI rates. Therefore, safe and durable long-term outcomes are achievable in single-stage AWR using xenogeneic mesh for CDC class III/IV defects., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: Disclosure: Dr. Butler is a consultant for Allergan, Tela Bio, and Bard (BD). Dr. Kapur has no conflicts of interest to report.

Although abdominally-based free flaps have long been the gold standard, the profunda artery perforator (PAP) flap has emerged as an important alternative option for autologous breast reconstruction. The aim of this study was to directly compare the donor site morbidity of using the PAP versus deep inferior epigastric perforator (DIEP) free flap., Methods: We performed a retrospective review of patients undergoing autologous breast reconstruction using a DIEP and/or PAP flap from January 2017 to December 2020. In total, 30 PAP flap patients were matched with 60 DIEP flap patients. Outcomes included donor site wound dehiscence, length of stay, narcotic consumption, and pain scores. Patient-reported outcomes for the thigh versus abdomen were compared using questions derived from the BREAST-Q., Results: There was no significant difference in length of stay ( P = 0.182), reoperation rates ( P = 0.999), flap failure rates ( P = 0.999), or donor site complications ( P = 0.999). Both groups had similar mean pain scores, maximum pain scores, daily and total narcotic requirements. In comparing the thigh or abdomen as a donor site, there was no difference in frequency of negative symptoms (difficulty with daily activities, discomfort, tightness, and negative impact on ability to work) or satisfaction scores as related to their appearance in and out of clothing and the appearance of the scar., Conclusions: The thigh and abdomen are both suitable donor sites for autologous breast reconstruction with similar flap-related and patient-reported outcomes. The ultimate decision regarding whether to use a PAP or DIEP flap for breast reconstruction should be tailored based on patient anatomy and preference., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)