Bio


Dr. Nazerali specializes in complex reconstruction, microsurgery, and aesthetic and cosmetic surgery. He excels at breast reconstruction using free autologous tissue and performs advanced techniques such as the minimally invasive superficial inferior epigastric artery (SIEA) flap, as well as the deep inferior epigastric artery perforator (DIEP) flap procedure. In addition to autologous reconstruction, Dr. Nazerali utilizes the latest techniques in implant-based breast reconstruction. His techniques and results have made him a leading instructor and lecturer at national and international institutions, societies and conferences.

In addition to breast reconstruction, Dr. Nazerali performs both aesthetic as well as whole body reconstructive procedures. He has a busy aesthetic practice focusing on breast augmentation, face and body rejuvenation as well as body contouring. In his reconstructive practice, he specializes in abdominal wall reconstruction as well as post-trauma tissue transfers. For every patient in his care, his goal is to optimize restoration of both form and function.

To help advance the field of plastic and reconstructive surgery, Dr. Nazerali conducts research into outcomes of breast reconstruction, augmentation, and reduction. Dr. Nazerali has published widely: well over 100 journal articles and conference proceedings. Topics include breast reconstruction after radiation; advances in surgical technique; and, the use of virtual, augmented, and mixed reality systems in plastic surgery practice and education. His work has appeared in Annals of Plastic Surgery, Plastic and Reconstructive Surgery, Surgery, the European Journal of Plastic Surgery, the Aesthetic Surgery Journal, and elsewhere.

Dr. Nazerali focuses not only on improving his patient’s lives but also our ability to deliver care as an institution. He is on the Medical Executive Council at Stanford Healthcare, serves as a committee member in the American Society of Plastic Surgeons as well as the California Society of Plastic Surgeons. In his spare time, he volunteers his time to provide reconstructive surgical services to adults and children in need worldwide.


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Clinical Focus


  • Plastic Surgery
  • Microsurgery
  • Breast Reconstruction
  • Abdominal Wall
  • Perforator Flap
  • Complex Reconstruction
  • Hand Surgery
  • DIEP, TRAM, SIEA, SGAP
  • Aesthetic Surgery
  • Cosmetic Surgery

Academic Appointments


Boards, Advisory Committees, Professional Organizations


  • Global Health Faculty Fellow, Stanford Center for Innovation in Global Health (CIGH) (2014 - Present)

Professional Education


  • Board Certification: American Board of Surgery, Plastic Surgery (2015)
  • Medical Education: Warren Alpert Medical School Brown University (2008) RI
  • BScH, Queen's University, Neuroscience (2002)
  • MHS, Johns Hopkins Medical Institutes, School of Public Health, International Health, Health Systems Management (2004)
  • Medical Education, Dartmouth College - School of Medicine, Preclinical Medicine (2006)
  • Internship: UC Davis Medical Center (2009) CA
  • Residency: UC Davis Medical Center (2013) CA
  • Fellowship, Stanford Hopsital & Clinics, Microsurgery and Complex Reconstruction (2014)

Stanford Advisees


All Publications


  • Impact of post-operative infection on revision procedures in breast reconstruction: A marketscan database analysis. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Francis, S. D., Kang, A. W., Maheta, B. J., Sangalang, B. R., Salingaros, S., Wu, R. T., Nazerali, R. S. 2024; 93: 103-110

    Abstract

    Esthetic complications, such as capsular contracture and soft-tissue contour defects, hinder the desired outcomes of breast reconstruction. As subclinical infection is a prevailing theory behind capsular contracture, we investigated the effects of post-operative infections on these issues and revision procedures.We conducted a retrospective database study (2007-2021) on breast reconstruction patients from the MarketScan® Databases. Esthetic complications were defined by their associated revision procedures and queried via CPT codes. Severe capsular contracture (Grade 3-4) was defined as requiring capsulotomy or capsulectomy with implant removal or replacement. Moderate and severe soft-tissue defects were determined by the need for fat grafting or breast revision, respectively. Generalized linear models were used, adjusting for comorbidities and surgical factors (p < 0.05).We analyzed the data on 62,510 eligible patients. Post-operative infections increased the odds of capsulotomy (OR 1.59, p < 0.001) and capsulectomy (OR 2.30, p < 0.001). They also raised the odds of breast revision for severe soft-tissue defects (OR 1.21, p < 0.001). There was no significant association between infections and fat grafting for moderate defects. Patients who had post-operative infections were also more likely to experience another infection after fat grafting (OR 3.39, p = 0.0018). In two-stage reconstruction, infection after tissue expander placement was associated with greater odds of infection after implant placement.Post-operative infections increase the likelihood of developing severe soft-tissue defects and capsular contracture requiring surgical revision. Our data reinforce the role of infections in the pathophysiology of capsular contracture. Additionally, infections elevate the risk of subsequent infections after fat grafting for moderate defects, further increasing patient morbidity.

    View details for DOI 10.1016/j.bjps.2024.04.031

    View details for PubMedID 38678812

  • Is immediate lymphatic reconstruction the future of lymphedema prevention? GLAND SURGERY Aristizabal, A., Ciudad, P., Chen, H., Maruccia, M., Nazerali, R., Manrique, O. J. 2024

    View details for DOI 10.21037/gs-23-536

    View details for Web of Science ID 001206763000001

  • Lymphadenectomy After Melanoma-A National Analysis of Recurrence Rates and Risk of Lymphedema. Annals of plastic surgery Shen, C., Shah, J. K., Cevallos, P., Nazerali, R., Rosen, J. M. 2024; 92 (4S Suppl 2): S284-S292

    Abstract

    Treatment for melanoma after a positive sentinel lymph node biopsy includes nodal observation or lymphadenectomy. Important considerations for management, however, involve balancing the risk of recurrence and the risk of lymphedema after lymphadenectomy.From the Merative MarketScan Research Databases, adult patients were queried from 2007 to 2021. International Classification of Disease, Ninth (ICD-9) and Tenth (ICD-10) Editions, diagnosis codes and Current Procedural Terminology codes were used to identify patients with melanoma diagnoses who underwent an index melanoma excision with a positive sentinel lymph node biopsy (SLNB). Main outcomes were completion lymph node dissection (CLND) utilization after a positive SLNB, developing lymphedema with or without CLND, and nodal basin recurrence 3 months or more after index excision. Subanalyses stratified by index excision year (2007-2017 and 2018-2021) and propensity score matched were additionally conducted. Demographics and comorbidities (measured by Elixhauser index) were recorded.A total of 153,085,453 patients were identified. Of those, 359,298 had a diagnosis of melanoma, and 202,456 patients underwent an excision procedure. The study cohort comprised 3717 patients with a melanoma diagnosis who underwent an excision procedure and had a positive SLNB. The mean age of the study cohort was 49 years, 57% were male, 41% were geographically located in the South, and 24% had an Elixhauser index of 4+. Among the 350 patients who did not undergo CLND, 10% experienced recurrence and 22% developed lymphedema. A total of 3367 patients underwent CLND, of which 8% experienced recurrence and 20% developed lymphedema. Completion lymph node dissection did not significantly affect risk of recurrence [odds ratio (OR), 1.370, P = 0.090] or lymphedema (OR, 1.114, P = 0.438). After stratification and propensity score matching, odds of experiencing lymphedema (OR, 1.604, P = 0.058) and recurrence (OR, 1.825, P = 0.058) after CLND were not significantly affected. Rates of CLND had significantly decreased (P < 0.001) overtime, without change in recurrence rate (P = 0.063).Electing for nodal observation does not increase the risk of recurrence or reduce risk of lymphedema. Just as CLND does not confer survival benefit, its decreased utilization has not increased recurrence rate.

    View details for DOI 10.1097/SAP.0000000000003867

    View details for PubMedID 38556691

  • A national analysis of burn injuries among homeless persons presenting to emergency departments. Burns : journal of the International Society for Burn Injuries Shah, J. K., Liu, F., Cevallos, P., Amakiri, U. O., Johnstone, T., Nazerali, R., Sheckter, C. C. 2024

    Abstract

    Burn injuries among the homeless are increasing as record numbers of people are unsheltered and resort to unsafe heating practices. This study characterizes burns in homeless encounters presenting to US emergency departments (EDs).Burn encounters in the 2019 Nationwide Emergency Department Sample (NEDS) were queried. ICD-10 and CPT codes identified homelessness, injury regions, depths, total body surface area (TBSA %), and treatment plans. Demographics, comorbidities, and charges were analyzed. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate modeling.Of 316,344 weighted ED visits meeting criteria, 1919 (0.6%) were homeless. Homeless encounters were older (mean age 44.83 vs. 32.39 years), male-predominant (71% vs. 52%), and had more comorbidities, and were more often White or Black race (p < 0.001). They more commonly presented to EDs in the West and were covered by Medicaid (51% vs. 33%) (p < 0.001). 12% and 5% of homeless burn injuries were related to self-harm and assault, respectively (p < 0.001). Homeless encounters experienced more third-degree burns (13% vs. 4%; p < 0.001), though TBSA % deciles were not significantly different (34% vs. 33% had TBSA % of ten or lower; p = 0.516). Homeless encounters were more often admitted (49% vs. 7%; p < 0.001), and homelessness increased odds of admission (OR 4.779; p < 0.001). Odds of transfer were significantly lower (OR 0.405; p = 0.021).Homeless burn ED encounters were more likely due to assault and self-inflicted injuries, and more severe. ED practitioners should be aware of these patients' unique presentation and triage to burn centers accordingly.

    View details for DOI 10.1016/j.burns.2024.02.030

    View details for PubMedID 38492979

  • Is there an ideal timing for autologous fat grafting in implant-based breast reconstruction? Commentary on a systematic review and meta-analysis. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Maheta, B., Yesantharao, P. S., Thawanyarat, K., Akhter, M. F., Rowley, M., Nazerali, R. S. 2024; 90: 171-172

    View details for DOI 10.1016/j.bjps.2024.02.045

    View details for PubMedID 38368759

  • Risk Factors for Hardware Removal Following Bimaxillary Surgery: A National Database Analysis. The Journal of craniofacial surgery Shah, J. K., Silverstein, M., Cevallos, P., Johnstone, T., Wu, R., Nazerali, R., Bruckman, K. 2024

    Abstract

    Orthognathic surgery typically relies on the rigid fixation of fracture fragments using metal hardware. Though hardware is usually intended to be implanted permanently, the removal of hardware (ROH) is sometimes indicated for a variety of reasons. The authors sought to identify risk factors for ROH following orthognathic surgery. The authors conducted a retrospective analysis of the Merative MarketScan Research Databases, 2007-2021 using Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and ICD-10) codes to identify patients who underwent an index Le Fort 1 osteotomy and bilateral sagittal split osteotomy operation on the same day. Statistical analysis involved χ2, Shapiro-Wilk, Wilcoxon-Mann-Whitney, Poisson regression, and multivariable logistic regression tests. 4698 patients met the inclusion criteria. The mean age at surgery was 25 years, and 57% were female. ROH occurred in 5.9% of patients. The mean time to hardware removal was 190.5±172.4 days. In a multivariate logistic regression, increased odds of ROH were associated with older patient age [OR: 1.02 (1.01-1.03), P=0.046], sleep apnea [OR: 1.62 (1.13-2.32), P=0.018], and craniofacial syndrome and/or cleft diagnoses [OR: 1.88 (1.14-2.55), P<0.001]. In the same model, postoperative oral antibiotic prophylaxis was not associated with ROH (P=0.494). The incidence of all-cause complications [IRR: 1.03 (1.01-1.05), P<0.001] rose over the study period, while the incidence of ROH did not change significantly (P=0.281). Patients at elevated risk should be counseled on the increased possibility of a second operation for ROH before having orthognathic surgery to ensure expectations and health care utilization decisions align with the evidence.

    View details for DOI 10.1097/SCS.0000000000009929

    View details for PubMedID 38231209

  • Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019. Annals of plastic surgery Shah, J. K., Amakiri, U. O., Cevallos, P., Yesantharao, P., Ayyala, H., Sheckter, C. C., Nazerali, R. 2024

    Abstract

    INTRODUCTION: Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States.METHODS: Using the National Inpatient Sample, 2016-2019, the International Classification of Disease, Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling.RESULTS: A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Delta = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Delta = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR (P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay (P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242).CONCLUSIONS: As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

    View details for DOI 10.1097/SAP.0000000000003764

    View details for PubMedID 38320006

  • Breast reconstruction after mastectomy in patients with obesity: a narrative review. Annals of translational medicine Cevallos, P., Berry, C., Lipman, K. J., Kubiak, C. A., Mohan, A. T., Ayyala, H. S., Manrique, O. J., Nazerali, R. 2023; 11 (12): 413

    Abstract

    Breast reconstruction in patients with obesity presents numerous challenges, both in terms of surgical technique and post-operative complication management. As breast reconstruction techniques continue to evolve, the armamentarium of reconstructive options for patients with obesity has vastly expanded. Options now include immediate or delayed, implant-based, autologous, or hybrid reconstruction. Determining the optimal breast reconstruction in this complex population requires nuanced and experienced decision-making.A literature search was conducted to identify studies assessing breast reconstruction considerations in patients with obesity. The search was performed on PubMed and was limited to English language studies published between 1990 and 2023. Primary studies, case reports, chart reviews, and qualitative studies were included. Additional articles were identified for inclusion based on a review of references, as well as a web-based search, to identify additional studies that were not captured with the primary search strategy.This narrative review article summarizes the current literature available to guide surgeons in breast reconstruction in patients with obesity.The advancements in oncologic surgery and breast reconstruction techniques have expanded available surgical options, including immediate or delayed implant-based, autologous, or hybrid breast reconstruction. Each approach has its unique advantages, disadvantages, and surgical considerations. Despite the challenges, patients with obesity can achieve favorable aesthetic outcomes through careful assessment of comorbidities and expectation management.

    View details for DOI 10.21037/atm-23-1599

    View details for PubMedID 38213816

    View details for PubMedCentralID PMC10777214

  • Prioritizing Native Breast Skin Preservation or Scar Symmetry in Autologous Breast Reconstruction? Using Crowdsourcing to Assess Preference. Eplasty Patel, A. A., Feng, C. L., Marquez, J., Spaw, J. P., Garza, R. M., Lee, G. K., Nazerali, R. S. 2023; 23: e75

    Abstract

    Recent literature on autologous breast reconstruction suggests that such factors as scar symmetry and skin paddle size impact patient preferences more than preservation of native breast skin. Since patient satisfaction with plastic surgery procedures can be largely influenced by beauty standards set by the general public, this study used a novel crowdsourcing method to evaluate laypeople's aesthetic preferences for different bilateral autologous breast reconstructions to determine the relative importance of scar and skin paddle symmetry and preservation of native skin.Using Amazon's Mechanical Turk crowdsourcing marketplace, participants ranked images of reconstructions based on overall aesthetic appearance. Images were digitally modified to reflect 4 types of reconstruction: immediate (IR), delayed symmetric (DS), delayed asymmetric (DA), or mixed (MR).DS was ranked most favorably (1.74), followed by IR (1.95), DA (2.93), and MR (3.34). Friedman rank sum and pairwise tests showed statistical significance for comparisons of all 4 reconstruction types. Likert ratings were higher for IR than for DA reconstructions for skin quality (P = .002), scar visibility (P < .001), scar position (P < .001), and breast symmetry, shape, and position (P < .001). Ratings increased for all aesthetic factors following nipple-areolar-complex reconstruction (P < .001).More symmetric breast scars were rated aesthetically higher than nonsymmetric scarring, and our participants preferred maintenance of scar symmetry over preservation of native breast skin. These findings are consistent with previous studies that surveyed non-crowdsourced participants, which demonstrates the potential for crowdsourcing to be used to better understand the general public's preferences in plastic surgery.

    View details for PubMedID 38229965

    View details for PubMedCentralID PMC10790140

  • US air pollution is associated with increased incidence of non-syndromic cleft lip/palate. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Krakauer, K. N., Cevallos, P. C., Amakiri, U. O., Saldana, G. M., Lipman, K. J., Howell, L. K., Wan, D. C., Khosla, R. K., Nazerali, R., Sheckter, C. C. 2023; 88: 344-351

    Abstract

    Maternal cigarette use is associated with the fetal development of orofacial clefts. Air pollution should be investigated for similar causation. We hypothesize that the incidence of non-syndromic cleft lip with or without palate (NSCLP) and non-syndromic cleft palate (NSCP) would be positively correlated with air pollution concentration.The incidence of NSCLP and NSCP per 1000 live births from 2016 to 2020 was extracted from the Centers for Disease Control and Prevention Vital Statistics Database and merged with national reports on air pollution using the Environmental Protection Agency Air Quality Systems annual data. The most commonly reported pollutants were analyzed including benzene, sulfur dioxide (SO2), particulate matter (PM) 2.5, PM 10, ozone (O3), and carbon monoxide (CO). Multivariable negative binomial and Poisson log-linear regression models evaluated the incidence of NSCLP and NSCP as a function of the pollutants, adjusting for race. All p-values are reported with Bonferroni correction.The median NSCLP incidence was 0.22/1000 births, and isolated NSCP incidence was 0.18/1000 births. For NSCLP, SO2 had a coefficient estimate (CE) of 0.60 (95% CI [0.23, 0.98], p < 0.007) and PM 2.5 had a CE of 0.20 (95% CI [0.10, 0.31], p < 0.005). Among isolated NSCP, no pollutants were found to be significantly associated.SO2 and PM 2.5 were significantly correlated with increased incidence of NSCLP. The American people and perinatal practitioners should be aware of the connection to allow for risk reduction and in utero screening.

    View details for DOI 10.1016/j.bjps.2023.11.012

    View details for PubMedID 38064913

  • Analyzing the Visibility of Gender-Affirming Surgery Education on US Plastic Surgery Residency Program Web Sites. Annals of plastic surgery Camacho, J. M., Najafali, D., Francis, S., Tople, T. L., Patel, H. S., Thawanyarat, K., Eggert, G. R., Calderon, T., Nazerali, R. S., Morrison, S. D. 2023; 91 (5): 518-523

    Abstract

    As the demand for gender affirmation grows, teaching gender-affirming surgery (GAS) in plastic and reconstructive surgery (PRS) programs has become increasingly important. Residency applicants interested in GAS often use program web sites to explore potential training opportunities. Our study aimed to quantify the GAS training opportunities promoted on residency program web sites and determine the characteristics of programs likely to promote GAS training.An assessment of 88 integrated PRS residency programs' web sites was conducted between 2021 and 2022. Plastic and reconstructive surgery residency and institutional webpages were queried for geographical location, training opportunities in GAS through residency or fellowship, and the number of faculty performing GAS. Descriptive statistics and multivariable regressions were used to describe and identify factors associated with increased GAS residency training opportunities.Twenty-six percent of PRS residencies mentioned training opportunities for GAS on their web sites. Gender-affirming surgery fellowships were offered at 7% of institutions, and an additional 7% were available via adjunct academic programs. Programs with faculty practicing GAS were 54% more likely to mention GAS on their residency page (odds ratio, 1.54; 95% confidence interval, 1.14-2.21; P = 0.009).Few PRS residency programs mention GAS on their web sites. As GAS becomes a more robust component of plastic surgery, appropriate information about the extent of GAS training should be available for applicants. Determining how local, state, and federal policies impact programs' abilities to highlight GAS should be investigated in future studies.

    View details for DOI 10.1097/SAP.0000000000003697

    View details for PubMedID 37823617

  • Travel distance and national access to gender-affirming surgery. Surgery Johnstone, T., Thawanyarat, K., Eggert, G. R., Navarro, Y., Rowley, M. A., Lane, M., Darrach, H., Nazerali, R., Morrison, S. D. 2023

    Abstract

    Gender-affirming surgery is unequally distributed across the United States due to resource allocation, state-based regulations, and the availability of trained physicians. Many individuals seeking gender-affirming surgery travel vast distances to receive care. This study aims to quantify the distances that individuals travel to receive gender-affirming surgery based on procedure type and patient home-of-record location.Patients in the Optum Clinformatics Data Mart who underwent gender-affirming surgery were identified via Current Procedural Terminology codes. Data on patient demographics, procedural care, and location of patient and provider were collected. To be included, a patient had to meet diagnostic criteria to receive gender-affirming surgery and have a recorded surgical procedure reimbursed as part of gender-affirming surgery per the Centers for Medicare and Medicaid Services guidelines. Patients residing or receiving care outside the continental United States were excluded. Distances between the ZIP Code of each patient's home of record and the location where the gender-affirming surgery was performed were calculated via the Google Maps Distance Matrix API. Distance traveled for gender-affirming surgery by patient state and gender-affirming surgery procedure were determined. Multivariate linear regression analysis determined predictors of distance traveled for gender-affirming surgery, whereas multivariate logistic regression identified variables associated with an increased likelihood of out-of-state travel to gender-affirming surgery.Across 86 million longitudinal patient records, the study population included 2,743 records corresponding to 1,735 patients who received gender-affirming surgery between January 2003 and June 2020. The median distance traveled for gender-affirming surgery was 191 miles (mean: 391.5), and 36.0% of patients traveled out of their state of residence. Every patient from West Virginia, Wyoming, South Dakota, Mississippi, and Delaware traveled out of state for gender-affirming surgery. Patients with homes of record in California (18.4%), Massachusetts (20.7%), and Oregon (19.0%) were the least likely to travel out-of-state for gender-affirming surgery out of states with more than 10 gender-affirming surgery encounters. The main predictors for out-of-state travel included both feminizing and masculinizing genital surgery, as well as an insurance coverage with increased provider options. Additionally, patients traveled shorter distances for gender-affirming surgery after the post-2014 Affordable Care Act expansion compared to pre-2014.Patients receiving gender-affirming surgery in the United States travel great distances for their care, often receiving their care from out-of-state providers. Restrictive guidelines imposed by state laws on both the access to and provision of gender-affirming surgery compound the myriad of common difficulties that patients face. It is imperative to discuss potential factors that may mitigate these barriers for those who require gender-affirming surgery.

    View details for DOI 10.1016/j.surg.2023.09.008

    View details for PubMedID 37839968

  • Allometrically scaling tissue forces drive pathological foreign-body responses to implants via Rac2-activated myeloid cells. Nature biomedical engineering Padmanabhan, J., Chen, K., Sivaraj, D., Henn, D., Kuehlmann, B. A., Kussie, H. C., Zhao, E. T., Kahn, A., Bonham, C. A., Dohi, T., Beck, T. C., Trotsyuk, A. A., Stern-Buchbinder, Z. A., Than, P. A., Hosseini, H. S., Barrera, J. A., Magbual, N. J., Leeolou, M. C., Fischer, K. S., Tigchelaar, S. S., Lin, J. Q., Perrault, D. P., Borrelli, M. R., Kwon, S. H., Maan, Z. N., Dunn, J. C., Nazerali, R., Januszyk, M., Prantl, L., Gurtner, G. C. 2023

    Abstract

    Small animals do not replicate the severity of the human foreign-body response (FBR) to implants. Here we show that the FBR can be driven by forces generated at the implant surface that, owing to allometric scaling, increase exponentially with body size. We found that the human FBR is mediated by immune-cell-specific RAC2 mechanotransduction signalling, independently of the chemistry and mechanical properties of the implant, and that a pathological FBR that is human-like at the molecular, cellular and tissue levels can be induced in mice via the application of human-tissue-scale forces through a vibrating silicone implant. FBRs to such elevated extrinsic forces in the mice were also mediated by the activation of Rac2 signalling in a subpopulation of mechanoresponsive myeloid cells, which could be substantially reduced via the pharmacological or genetic inhibition of Rac2. Our findings provide an explanation for the stark differences in FBRs observed in small animals and humans, and have implications for the design and safety of implantable devices.

    View details for DOI 10.1038/s41551-023-01091-5

    View details for PubMedID 37749310

    View details for PubMedCentralID 2966551

  • Timing of autologous fat grafting in implant-based breast reconstruction: Best practices based on systematic review and meta-analysis. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Maheta, B., Yesantharao, P. S., Thawanyarat, K., Akhter, M. F., Rowley, M., Nazerali, R. S. 2023; 86: 273-279

    Abstract

    Fat grafting is commonly undertaken as a third-stage procedure in patients with staged implant-based breast reconstruction (IBR). However, fat grafting performed during second-stage expander/implant exchange provides faster results without an additional procedure and associated risks (Patel et al., 2020). We previously demonstrated that fat grafting during second-stage expander/implant exchange did not increase clinical complications (Patel et al., 2020). As a corollary, this study investigates patients' satisfaction with second- versus third-stage fat grafting to help establish a set of best practices for the timing of fat grafting in such patients.A review of PubMed/MEDLINE databases (2010-2022) was performed to identify articles investigating the quality of life in patients undergoing second- or third-stage fat grafting after IBR. BREAST-Q scores were pooled using random-effects modeling and the DerSimonian-Laird method. Post-hoc sensitivity analyses were completed using the Hartung-Knapp-Sidik-Jonkman method. The Haldane-Anscombe correction was used for outcomes with low counts. All study analyses adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Six studies (216 patients) were included. Pooled random-effects modeling demonstrated no significant changes in BREAST-Q satisfaction with outcome scores when comparing patients who received second- versus third-stage fat grafting (p = 0.178) with results robust to sensitivity analyses. In addition, pooled analyses of the available data demonstrated that second-stage fat grafting did not increase downstream revision surgery needs compared to third-stage fat grafting.In combination with our prior work, this meta-analysis suggests that second-stage fat grafting provides not only equivalent but improved clinical and quality of life outcomes with fewer procedures in patients undergoing expander/IBR.

    View details for DOI 10.1016/j.bjps.2023.09.026

    View details for PubMedID 37797375

  • What Do Patients Look for When Scheduling Their Initial Elective Aesthetic Plastic Surgery Consultation? Aesthetic plastic surgery Fung, E., Cevallos, P., Thawanyarat, K., Rowley, M., Navarro, Y., Sheckter, C., Nazerali, R. 2023

    Abstract

    Multiple factors influence patients when deciding on where to seek plastic surgery consultations. Our objective was to determine the most important factors when booking the initial consultation.A 23 question survey was distributed online via Amazon Mechanical Turk targeting participants who had prior plastic surgery consultations or were planning to have one in the future. Participant demographic data were collected, and participants were asked to rank the importance of factors related to cost, surgeon reputation, social media, technology, amenities, accessibility, and appointment details on a 1-5 Likert scale. Rankings were reported by mean and standard deviation.A total of 593 responses were gathered. 48.1% of participants were 25-34 years of age, 54.6% were female, 66.3% identified as White, 78.4% were located in the U.S, and 54.5% had a bachelor's degree. Participants rated the importance of a surgeon's online reviews (mean 4.15, SD 0.81), surgeon presence at follow-up visits (mean 4.01, SD 0.91), and availability of pricing prior to appointment (mean 4.01, SD 0.91) the highest. The least important factors were waiting room amenities and social media advertising. Individuals younger than 45 were more likely to rate a surgeon's social media presence higher than those 45 years and older (OR 2.02; 95%CI [1.37-2.96]; p < 0.001).Patients considered surgeon's online reviews, presence at follow-up visits, and the availability of pricing information the most important when booking a plastic surgery consultation. These findings may assist physicians in structuring plastic surgery consultations based on factors important to patients.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

    View details for DOI 10.1007/s00266-023-03609-3

    View details for PubMedID 37620567

    View details for PubMedCentralID 4127729

  • Improving Operating Room Efficiency Through Reducing First Start Delays in an Academic Center. Journal for healthcare quality : official publication of the National Association for Healthcare Quality Singh, D., Cai, L., Watt, D., Scoggins, E., Wald, S., Nazerali, R. 2023

    Abstract

    BACKGROUND: Delays in operating room (OR) first-case start times can cause additional costs for hospitals, healthcare team frustration and delay in patient care. Here, a novel process improvement strategy to improving first-case start times is presented.METHODS: First case in room start times were recorded for ORs at an academic medical center. Three interventions-automatic preoperative orders, dot phrases to permit re-creation of unavailable consent forms, and improved H&P linking to the surgical encounter-were implemented to target documentation-related delays. Monthly percentages of first-case on-time starts (FCOTS) and time saved were compared with the "preintervention" time period, and total cost savings were estimated.RESULTS: During the first 3-months after implementation of the interventions, the percentage of FCOTS improved from an average of 36.7%-52.7%. Total time savings across all ORs over the same time period was found to be 55.63 hours, which is estimated to have saved a total of $121,834.52 over the 3-month interventional period.CONCLUSIONS: By implementing multiple quality improvement interventions, delays to first start in room OR cases can be meaningfully reduced. Quality improvement protocols targeted toward root causes of OR delays can be a significant driver to reduce healthcare costs.

    View details for DOI 10.1097/JHQ.0000000000000398

    View details for PubMedID 37596242

  • Factors contributing to prolonged drain duration in prepectoral staged implant-based breast reconstruction EUROPEAN JOURNAL OF PLASTIC SURGERY Thawanyarat, K., Shah, J. K., Eggert, G., Rowley, M., Kim, T., Yesantharao, P. S., Turner, E., Thornton, B., Nazerali, R. 2023
  • Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-To-Implant Trends. Plastic and reconstructive surgery Yesantharao, P. S., Arquette, C., Cheesborough, J. E., Lee, G. K., Nazerali, R. S. 2023

    Abstract

    Direct-to-implant breast reconstruction is an attractive choice for appropriately-selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value healthcare, therefore, it is important to investigate utilization of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis.This was a retrospective investigation of direct-to-implant reconstruction between 2010-2018 in the United States, using the National Inpatient Sample (NIS) database. All study analyses were undertaken using Stata v15.0.The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010-2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures significantly increased (p=0.03), relative to staged and delayed implant-based procedures. While direct-to-implant patients were younger, more likely to be white and privately-insured, the proportion of non-white, publicly-insured patients undergoing direct-to-implant reconstruction significantly increased by 2018 (p<0.05). Furthermore, direct-to-implant utilization amongst Medicaid patients increased at 2.2 times the rate in Medicaid expansion states compared to non-expansion states. Direct-to-implant patients had significantly higher APR-DRG risk scores in 2018 than in 2010 (p=0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures (p=0.03), when considering expander placement and expander-implant exchange.Overall, utilization of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate.

    View details for DOI 10.1097/PRS.0000000000010826

    View details for PubMedID 37352460

  • Commentary on: Performance of ChatGPT on the Plastic Surgery Inservice Training Examination. Aesthetic surgery journal Cevallos, P. C., Nazerali, R. S. 2023

    View details for DOI 10.1093/asj/sjad171

    View details for PubMedID 37265091

  • How Postoperative Infection Affects Reoperations after Implant-based Breast Reconstruction: A National Claims Analysis of Abandonment of Reconstruction. Plastic and reconstructive surgery. Global open Francis, S. D., Thawanyarat, K., Johnstone, T. M., Yesantharao, P. S., Kim, T. S., Rowley, M. A., Sheckter, C. C., Nazerali, R. S. 2023; 11 (6): e5040

    Abstract

    Infection after implant-based breast reconstruction adversely affects surgical outcomes and increases healthcare utilization. This study aimed to quantify how postimplant breast reconstruction infections impact unplanned reoperations, hospital length of stay, and discontinuation of initially desired breast reconstruction.We conducted a retrospective cohort study using Optum's de-identifed Clinformatics Data Mart Database to analyze women undergoing implant breast reconstruction from 2003 to 2019. Unplanned reoperations were identified via Current Procedural Terminology (CPT) codes. Outcomes were analyzed via multivariate linear regression with Poisson distribution to determine statistical significance at P < 0.00625 (Bonferroni correction).In our national claims-based dataset, post-IBR infection rate was 8.53%. Subsequently, 31.2% patients had an implant removed, 6.9% had an implant replaced, 3.6% underwent autologous salvage, and 20.7% discontinued further reconstruction. Patients with a postoperative infection were significantly associated with increased incidence rate of total reoperations (IRR, 3.11; 95% CI, 2.92-3.31; P < 0.001) and total hospital length of stay (IRR, 1.55; 95% CI, 1.48-1.63; P < 0.001). Postoperative infections were associated with significantly increased odds of abandoning reconstruction (OR, 2.92; 95% CI, 0.081-0.11; P < 0.001).Unplanned reoperations impact patients and healthcare systems. This national, claims-level study shows that post-IBR infection was associated with a 3.11× and 1.55× increase in the incidence rate of unplanned reoperations and length of stay. Post-IBR infection was associated with 2.92× increased odds of abandoning further reconstruction after implant removal.

    View details for DOI 10.1097/GOX.0000000000005040

    View details for PubMedID 37325376

    View details for PubMedCentralID PMC10263246

  • The Geographical Impact of Plastic Surgery Residency to Fellowship and Residency/Fellowship to First Job Placement. Annals of plastic surgery Maheta, B., Eggert, G. R., Thawanyarat, K., Patel, A. A., Sheckter, C. C., Nazerali, R. 2023; 90 (6): 603-610

    Abstract

    The location of trainees' plastic surgery residency or fellowship has implications on their subsequent careers, which can inform future trainees and faculty decisions, and may affect access to care nationwide. This study explores historic geographic trends of the location where trainees complete residency or fellowship and where they pursue a fellowship program or first job.Graduates from US integrated plastic surgery residency or fellowship programs from 2015 to 2021 were identified along with their proximity to fellowship or first job. Location was categorized based on whether the graduate's fellowship/first job location to residency/fellowship was within 100 miles, the same state, the same geographic region, the United States, or international. A χ2 value was calculated to determine the significance of relative geographical location after training.Three hundred sixty-five graduates that attended fellowship were included, representing 76.5% (65/85) of integrated plastic surgery residency programs. There were 47.7% (n = 174) that stayed within the same geographic region and 3.6% (n = 13) pursued training internationally. The location of the residency or fellowship program appears to have an influence on the location of the graduate's fellowship or first job.Graduates who completed integrated residency or fellowship in a certain geographic location were more likely to stay in that area for their fellowship or first job. This may be explained by graduates continuing training with their original program, the established network, and personal factors such as family and friends.

    View details for DOI 10.1097/SAP.0000000000003572

    View details for PubMedID 37311316

  • Targeting Vulnerability in the Homeless-A National Analysis of Burn Injuries Presenting to the Emergency Department Shah, J., Liu, F., Cevallos, P., Amakiri, U., Johnstone, T., Sheckter, C., Nazerali, R. OXFORD UNIV PRESS. 2023: S6
  • Factors Contributing to Prolonged Drain Duration in Prepectoral Staged Implant-based Breast Reconstruction Thawanyarat, K., Shah, J. K., Rowley, M., Eggert, G., Kim, T., Nazerali, R. LIPPINCOTT WILLIAMS & WILKINS. 2023: S92
  • Location Matters: The Geographical Impact of Plastic Surgery Residency to First Job Placement Eggert, G., Patel, A. A., Thawanyarat, K., Maheta, B., Nazerali, R. LIPPINCOTT WILLIAMS & WILKINS. 2023: S92-S93
  • Where To Next? Geographical Impact of Plastic Surgery Residency to Fellowship Placement Thawanyarat, K., Patel, A. A., Maheta, B., Eggert, G., Nazerali, R. LIPPINCOTT WILLIAMS & WILKINS. 2023: S95
  • The Geographical Impact of Plastic Surgery Fellowship to First Job Placement Maheta, B., Patel, A. A., Eggert, G., Thawanyarat, K., Nazerali, R. LIPPINCOTT WILLIAMS & WILKINS. 2023: S94-S95
  • Stapled Single-Incision Ventral Hernia Repair Johnstone, T., Rowley, M., Banaschak, C., Nazerali, R. LIPPINCOTT WILLIAMS & WILKINS. 2023: S45
  • A Systematic Review and Meta-Analysis Comparing the Clinical Outcomes of Profunda Artery Perforator Versus Gracilis Thigh Flap as a Second Choice for Autologous Breast Reconstruction. Annals of plastic surgery Borrelli, M. R., Spake, C. S., Rao, V., Sinha, V., Crozier, J. W., Basta, M. N., Lee, G. K., Kwan, D. K., Nazerali, R. 2023; 90 (5S Suppl 3): S256-S267

    Abstract

    Autologous breast reconstruction remains a versatile option to produce a natural appearing breast after mastectomy. The deep inferior epigastric perforator remains the most commonly used flap choice, but when this donor site is unsuitable or unavailable, the transverse upper gracilis (TUG) or profunda artery perforator (PAP) flaps are popular secondary alternatives. We conduct a meta-analysis to better understand patient outcomes and adverse events in secondary flap selection in breast reconstruction.A systematic search was conducted on MEDLINE and Embase for all articles published on TUG and/or PAP flaps for oncological breast reconstruction in postmastectomy patients. A proportional meta-analysis was conducted to statistically compare outcomes between PAP and TUG flaps.The TUG and PAP flaps were noted to have similar reported rates of success and incidences of hematoma, flap loss, and flap healing (P > 0.05). The TUG flap was noted to have significantly more vascular complications (venous thrombosis, venous congestion, and arterial thrombosis) than the PAP flap (5.0% vs 0.6%, P < 0.01) and significantly greater rates of unplanned reoperations in the acute postoperative period (4.4% vs 1.8%, P = 0.04). Infection, seroma, fat necrosis, donor healing complications, and rates of additional procedures all exhibited high degree of heterogeneity precluding mathematical synthesis of outcomes across studies.Compared with TUG flaps, PAP flaps have fewer vascular complications and fewer unplanned reoperations in the acute postoperative period. There is need for greater homogeneity in reported outcomes between studies to enable for synthesis of other variables important in determining flap success.

    View details for DOI 10.1097/SAP.0000000000003226

    View details for PubMedID 37227406

  • Comparing the Outcomes and Complication Rates of Biologic vs Synthetic Meshes in Implant-Based Breast Reconstruction: A Systematic Review. Annals of plastic surgery Makarewicz, N., Perrault, D., Sharma, A., Shaheen, M., Kim, J., Calderon, C., Sweeney, B., Nazerali, R. 2023; 90 (5): 516-527

    Abstract

    This systematic review evaluates all published studies comparing biologic and synthetic meshes in implant-based breast reconstruction (IBBR), to determine which category of mesh produces the most favorable outcomes.Breast cancer is the most common cancer in women globally. Implant-based breast reconstruction is currently the most popular method of postmastectomy reconstruction, and recently, the use of surgical mesh in IBBR has become commonplace. Although there is a long-standing belief among surgeons that biologic mesh is superior to synthetic mesh in terms of surgical complications and patient outcomes, few studies exist to support this claim.A systematic search of the EMBASE, PubMed, and Cochrane databases was performed in January 2022. Primary literature studies comparing biologic and synthetic meshes within the same experimental framework were included. Study quality and bias were assessed using the validated Methodological Index for Non-Randomized Studies criteria.After duplicate removal, 109 publications were reviewed, with 12 meeting the predetermined inclusion criteria. Outcomes included common surgical complications, histological analysis, interactions with oncologic therapies, quality of life measures, and esthetic outcomes. Across all 12 studies, synthetic meshes were rated as at least equivalent to biologic meshes for every reported outcome. On average, the studies in this review tended to have moderate Methodological Index for Non-Randomized Studies scores.This systematic review offers the first comprehensive evaluation of all publications comparing biologic and synthetic meshes in IBBR. The consistent finding that synthetic meshes are at least equivalent to biologic meshes across a range of clinical outcomes offers a compelling argument in favor of prioritizing the use of synthetic meshes in IBBR.

    View details for DOI 10.1097/SAP.0000000000003512

    View details for PubMedID 37146317

  • Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis. Journal of racial and ethnic health disparities Johnstone, T., Thawanyarat, K., Rowley, M., Francis, S., Camacho, J. M., Singh, D., Navarro, Y., Shah, J. K., Nazerali, R. S. 2023

    Abstract

    Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data.Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated.From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively.Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

    View details for DOI 10.1007/s40615-023-01599-1

    View details for PubMedID 37074634

    View details for PubMedCentralID 8027914

  • Use of Local Antibiotic Delivery Systems in Tissue Expander and Implant-Based Breast Reconstruction: A Systematic Review of the Literature. Eplasty Makarewicz, N., Lipman, K., Johnstone, T., Shaheen, M., Shah, J. K., Nazerali, R. 2023; 23: e24

    Abstract

    Periprosthetic infections are a debilitating complication of alloplastic breast reconstruction. Local antibiotic delivery for prophylaxis and infection clearance has been used by other surgical specialties but rarely in breast reconstruction. Because local delivery can maintain high antibiotic concentrations with lower toxicity risk, it may be valuable for infection prophylaxis or salvage in breast reconstruction.A systematic search of the Embase, PubMed, and Cochrane databases was performed in January 2022. Primary literature studies examining local antibiotic delivery systems for either prophylaxis or salvage of periprosthetic infections were included. Study quality and bias were assessed using the validated MINORS criteria.Of 355 publications reviewed, 8 met the predetermined inclusion criteria; 5 papers investigated local antibiotic delivery for salvage, and 3 investigated infection prophylaxis. Implantable antibiotic delivery devices included polymethylmethacrylate, calcium sulfate, and collagen sponges impregnated with antibiotics. Non-implantable antibiotic delivery methods used irrigation with antibiotic solution into the breast pocket. All studies indicated that local antibiotic delivery was either comparable or superior to conventional methods in both the salvage and prophylaxis settings.Despite varied sample sizes and methodologies, all papers endorsed local antibiotic delivery as a safe, effective method of preventing or treating periprosthetic infections in breast reconstruction.

    View details for DOI 10.1002/bjs5.50324

    View details for PubMedID 37187864

    View details for PubMedCentralID PMC10176462

  • Is Plastic Surgery Training Equitable? An Analysis of Health Equity across US Plastic Surgery Residency Programs. Plastic and reconstructive surgery. Global open Cevallos, P., Amakiri, U. O., Johnstone, T., Kim, T. S., Maheta, B., Nazerali, R., Sheckter, C. 2023; 11 (4): e4900

    Abstract

    Achieving health equity includes training surgeons in environments exemplifying access, treatment, and outcomes across the racial, ethnic, and socioeconomic spectrum. Increased attention on health equity has generated metrics comparing hospitals. To establish the quality of health equity in plastic and reconstructive surgery (PRS) residency training, we determined the mean equity score (MES) across training hospitals of US PRS residencies.Methods: The 2021 Lown Institute Hospital Index database was merged with affiliated training hospitals of US integrated PRS residency programs. The Lown equity category is composed of three domains (community benefit, inclusivity, pay equity) generating a health equity grade. MES (standard deviation) was calculated and reported for residency programs (higher MES represented greater health equity). Linear regression modeled the effects of a program's number of training hospitals, safety net hospitals, and geographical region on MES.Results: The MES was 2.64 (0.62). An estimated 5.9% of programs had an MES between 1-2. In total, 56.5% of programs had an MES between 2 and 3, and 37.7% had an MES of 3 or more. The southern region was associated with a higher MES compared with the reference group (Northeast) (P = 0.03). The number of safety net hospitals per program was associated with higher MES (P = 0.02).Conclusions: Two out of three programs train residents in facilities failing to demonstrate high equity healthcare. Programs should promote health equity by diversifying care delivery through affiliated hospitals. This will aid in the creation of a PRS workforce trained to provide care for a socioeconomically, racially, and ethnically diverse population.

    View details for DOI 10.1097/GOX.0000000000004900

    View details for PubMedID 37035124

  • Google Trends and Injectable Products: The Next-Best Tool for Anticipating Patient Concerns in Plastic and Reconstructive Surgery. Archives of plastic surgery Rowley, M. A., Thawanyarat, K., Shah, J. K., Nazerali, R. 2023; 50 (2): 210-212

    View details for DOI 10.1055/s-0043-1762914

    View details for PubMedID 36999157

    View details for PubMedCentralID PMC10049800

  • Postoperative Antibiotics Confer No Protective Association After Fat Grafting for Breast Reconstruction. Annals of plastic surgery Thawanyarat, K., Johnstone, T., Rowley, M., Kim, T., Francis, S., Barrera, J., Cheeseborough, J., Sheckter, C., Nazerali, R. 2023

    Abstract

    INTRODUCTION: Autologous fat grafting after breast reconstruction is a commonly used technique to address asymmetry and irregularities in breast contour. While many studies have attempted to optimize patient outcomes after fat grafting, a key postoperative protocol that lacks consensus is the optimal use of perioperative and postoperative antibiotics. Reports suggest that complication rates for fat grafting are low relative to rates after reconstruction and have been shown to not be correlated to antibiotic protocol. Studies have additionally demonstrated that the use of prolonged prophylactic antibiotics do not lower the complication rates, stressing the need for a more conservative, standardized antibiotic protocol. This study aims to identify the optimal use of perioperative and postoperative antibiotics that optimizes patient outcomes.METHODS: Patients in the Optum Clinformatics Data Mart who underwent all billable forms of breast reconstruction followed by fat grafting were identified via Current Procedural Terminology codes. Patients meeting inclusion criteria had an index reconstructive procedure at least 90 days before fat grafting. Data concerning these patient's demographics, comorbidities, breast reconstructions, perioperative and postoperative antibiotics, and outcomes were collected via querying relevant reports of Current Procedural Terminology; International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; National Drug Code Directory, and Healthcare Common Procedure Coding System codes. Antibiotics were classified by type and temporal delivery: perioperatively or postoperatively. If a patient received postoperative antibiotics, the duration of antibiotic exposure was recorded. Outcomes analysis was limited to the 90-day postoperative period. Multivariable logistic regression was performed to ascertain the effects of age, coexisting conditions, reconstruction type (autologous or implant-based), perioperative antibiotic class, postoperative antibiotic class, and postoperative antibiotic duration on the likelihood of any common postoperative complication occurring. All statistical assumptions made by logistic regression were met successfully. Odds ratios and corresponding 95% confidence intervals were calculated.RESULTS: From more than 86 million longitudinal patient records between March 2004 and June 2019, our study population included 7456 unique records of reconstruction-fat grafting pairs, with 4661 of those pairs receiving some form of prophylactic antibiotics. Age, prior radiation, and perioperative antibiotic administration were consistent independent predictors of increased all-cause complication likelihood. However, administration of perioperative antibiotics approached a statistically significant protective association against infection likelihood. No postoperative antibiotics of any duration or class conferred a protective association against infections or all-cause complications.CONCLUSIONS: This study provides national, claims-level support for antibiotic stewardship during and after fat grafting procedures. Postoperative antibiotics did not confer a protective benefit association against infection or all-cause complication likelihood, while administering perioperative antibiotics conferred a statistically significant increase in the likelihood that a patient experienced postoperative complication. However, perioperative antibiotics approach a significant protective association against postoperative infection likelihood, in line with current guidelines for infection prevention. These findings may encourage the adoption of more conservative postoperative prescription practices for clinicians who perform breast reconstruction, followed by fat grafting, reducing the nonindicated use of antibiotics.

    View details for DOI 10.1097/SAP.0000000000003420

    View details for PubMedID 36880783

  • A recent national analysis of breast reconstruction outcomes in patients with underlying autoimmune connective tissue diseases EUROPEAN JOURNAL OF PLASTIC SURGERY Rowley, M. A., Thawanyarat, K., Shah, J. K., Yesantharao, P. S., Nazerali, R. 2023
  • Optimizing postoperative outcomes following neoadjuvant chemotherapy and mastectomy with immediate reconstruction: A national analysis. Journal of surgical oncology Thawanyarat, K., Johnstone, T., Rowley, M., Navarro, Y., Hinson, C., Nazerali, R. S. 2023

    Abstract

    The optimal timing between last neoadjuvant chemotherapy (NAC) session and mastectomy with immediate reconstruction (MIR) procedures has sparse data to support optimization of postoperative outcomes. Current literature suggests that timing is not a predictor of complications in patients undergoing implant-based reconstruction following NAC and other literature suggests guidelines based on tumor staging. To the best of our knowledge, this is the largest and most recent study characterizing the effect of time between NAC and mastectomy with immediate reconstruction on postoperative complications.Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction following NAC were identified via CPT and ICD-10 codes. Data concerning these patient's demographics, comorbidities, oncologic treatment, and outcomes were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. To meet inclusion criteria, patients needed to have an encounter for antineoplastic chemotherapy within 1 year of their associated reconstruction. Patients with other invasive procedures unrelated to their mastectomy-reconstruction pairing within 90 days of reconstruction were excluded. Outcomes analysis was limited to the 90-day postoperative period. The time between the last recorded chemotherapy encounter and breast reconstruction was computed. A multivariate logistic regression analysis was performed to ascertain the effects of age, race, coexisting conditions, reconstruction type (autologous or implant-based), and time between NAC and reconstruction on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated.From over 86 million longitudinal patient records, our study population included 139 897 4371 patient records corresponding to 13 399 3759 patients who had NAC and breast reconstruction between January 2003, October 2015, and June 2019. Increased time between last antineoplastic chemotherapy and MIR reconstruction was a statistically significant, independent predictor of decreased complication likelihood. By contrast, autologous reconstruction, hypertension, and type II diabetes mellitus, and African American, White, and Hispanic race (relative to Asian) had statistically significant associations with increased complication likelihood. Waiting an additional day between a patient's most recent chemotherapy session and MIR reconstruction reduces the odds of a complication occurring by 0.25%. This corresponds to reduction in odds of complication occurrence of approximately 7% for each month between neoadjuvant therapy and breast reconstruction.Increased time between NAC and MIR immediate reconstruction decreases the likelihood of experiencing one or more postoperative complications. Ideal time delay between 4 and 8 weeks has been shown to provide the best benefit for future breast reconstrution outcomes. In consultation with the oncologist, this information can be used to balance postoperative complication risk with increased oncologic risk in delaying mastectomy with immediate reconstruction.

    View details for DOI 10.1002/jso.27196

    View details for PubMedID 36602535

  • Use of Antibiotic-impregnated Polymethylmethacrylate (PMMA) Plates for Prevention of Periprosthetic Infection in Breast Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Johnstone, T., Lipman, K., Makarewicz, N., Shah, J., Turner, E., Posternak, V., Chang, D., Thornton, B., Nazerali, R. 2023; 11 (1)
  • Use of Antibiotic-impregnated Polymethylmethacrylate (PMMA) Plates for Prevention of Periprosthetic Infection in Breast Reconstruction. Plastic and reconstructive surgery. Global open Johnstone, T., Lipman, K., Makarewicz, N., Shah, J., Turner, E., Posternak, V., Chang, D., Thornton, B., Nazerali, R. 2023; 11 (1): e4764

    Abstract

    Periprosthetic infections remain a major challenge for breast reconstruction. Local antibiotic delivery systems, such as antibiotic beads and spacers, have been widely used within other surgical fields, but their use within plastic surgery remains scarce. In this study, we demonstrate the use of antibiotic-impregnated polymethylmethacrylate (PMMA) plates for infection prophylaxis in tissue expander (TE)-based breast reconstruction.A retrospective review of patients who underwent immediate breast reconstruction with prepectoral TEs over the span of 5 years performed by two surgeons was completed, revealing a total of 447 patients. Data pertaining to patient demographics, operative details, and postoperative outcomes were recorded. Fifty patients underwent TE reconstruction with the addition of a PMMA plate (Stryker, Kalamazoo, Michigan) impregnated with tobramycin and vancomycin. Antibiotic plates were removed at the time of TE-to-implant exchange. Patient-matching analysis was performed using the 397 patients without PMMA plates to generate a 50-patient nonintervention cohort for statistical analysis.The intervention cohort (n = 50) and 1:1 patient-matched nonintervention cohort (n = 50) demonstrated no statistically significant differences in patient demographics or operative characteristics other than PMMA plate placement. The rate of operative periprosthetic infection was 4% in the intervention group and 14% in the nonintervention group (P = 0.047). The rate of TE explantation was also reduced in the intervention group (6% versus 18%; P = 0.036). Follow-up averaged 9.1 and 8.9 months for the intervention and nonintervention groups, respectively (P = 0.255).Local antibiotic delivery using antibiotic-impregnated PMMA plates can be safely and effectively used for infection prevention with TE-based breast reconstruction.

    View details for DOI 10.1097/GOX.0000000000004764

    View details for PubMedID 36776590

    View details for PubMedCentralID PMC9911200

  • The Impact of Oncoplastic Reduction on Initiation of Adjuvant Radiation and Need for Reexcision: A Database Evaluation. Annals of plastic surgery Shah, J. K., Lipman, K., Pedreira, R., Makarewicz, N., Nazerali, R. 2022; 89 (6): e11-e17

    Abstract

    INTRODUCTION: Partial breast reconstruction with oncoplastic reduction can provide breast cancer patients with improved aesthetic outcomes after breast conservation therapy. This study evaluates the implications of simultaneous oncoplastic reduction with lumpectomy on complication rates, time to adjuvant radiation therapy, and rates of margin reexcision compared with lumpectomy alone.METHODS: The Clinformatics Data Mart Database is a national deidentified commercial claims data warehouse. From 2003 to 2020, adult female patients were queried to identify patients with a breast cancer diagnosis with International Classification of Disease codes. Among those, current procedural terminology codes were used to identify those who underwent lumpectomy alone versus lumpectomy with oncoplastic reduction. Patient demographics, complications, adjuvant oncologic therapies, and need for reexcision were recorded. Patients not continuously enrolled for at least 6 months before and after the index procedure were excluded. Multivariable regression and chi 2 tests were used for statistical analysis.RESULTS: Of 53,165 patients meeting criteria (mean age, 61.4 ± 11.6 years), 1552 (2.9%) underwent oncoplastic reduction. Diagnoses of most nonsurgical complications (seroma, wound dehiscence, postoperative infection, fat necrosis, tissue necrosis, and nonspecified complications of surgical care) were significantly higher in the oncoplastic reduction group, as were rates of some surgical complications (hematoma, seroma, and tissue debridement). However, undergoing oncoplastic reduction did not impact time to adjuvant radiation ( P = 0.194) and protected against positive margins requiring repeat lumpectomy or completion mastectomy ( P < 0.001).CONCLUSIONS: In patients undergoing breast conservation therapy, simultaneous oncoplastic reduction decreased occurrence of positive margins and did not impact time to adjuvant radiation therapy despite increased rates of surgical and nonsurgical complications.

    View details for DOI 10.1097/SAP.0000000000003313

    View details for PubMedID 36416687

  • Outcomes of Biosynthetic and Synthetic Mesh in Ventral Hernia Repair. Plastic and reconstructive surgery. Global open Sivaraj, D., Fischer, K. S., Kim, T. S., Chen, K., Tigchelaar, S. S., Trotsyuk, A. A., Gurtner, G. C., Lee, G. K., Henn, D., Nazerali, R. S. 2022; 10 (12): e4707

    Abstract

    The introduction of mesh for reinforcement of ventral hernia repair (VHR) led to a significant reduction in hernia recurrence rates. However, it remains controversial whether synthetic or biologic mesh leads to superior outcomes. Recently, hybrid mesh consisting of reinforced biosynthetic ovine rumen (RBOR) has been developed and aims to combine the advantages of biologic and synthetic mesh; however, outcomes after VHR with RBOR have not yet been compared with the standard of care.Methods: We performed a retrospective analysis on 109 patients, who underwent VHR with RBOR (n = 50) or synthetic polypropylene mesh (n = 59). Demographic characteristics, comorbidities, postoperative complications, and recurrence rates were analyzed and compared between the groups. Multivariate logistic regression models were fit to assess associations of mesh type with overall complications and surgical site occurrence (SSO).Results: Patients who underwent VHR with RBOR were older (mean age 63.7 versus 58.8 years, P = 0.02) and had a higher rate of renal disease (28.0 versus 10.2%, P = 0.01) compared with patients with synthetic mesh. Despite an unfavorable risk profile, patients with RBOR had lower rates of SSO (16.0 versus 30.5%, P = 0.12) and similar hernia recurrence rates (4.0 versus 6.78%, P = 0.68) compared with patients with synthetic mesh. The use of synthetic mesh was significantly associated with higher odds for overall complications (3.78, P < 0.05) and SSO (3.87, P < 0.05).Conclusion: Compared with synthetic polypropylene mesh, the use of RBOR for VHR mitigates SSO while maintaining low hernia recurrence rates at 30-month follow-up.

    View details for DOI 10.1097/GOX.0000000000004707

    View details for PubMedID 36530858

  • Risk stratification in subpectoral to prepectoral pocket conversion to reduce post-reconstruction animation deformity. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Cerceo, J. R., Cai, L., Yesantharao, P., Thornton, B., Nazerali, R. 2022; 77: 253-261

    Abstract

    BACKGROUND: Animation deformity is a morbid complication that impacts women undergoing subpectoral implant-based breast reconstruction. Transferring implants from the subpectoral to prepectoral space, pocket conversion, can be performed to minimize this issue. While prior literature has evaluated outcomes associated with this procedure, we investigated the risk factors most commonly associated with post-conversion complications.METHODS: We performed a retrospective cohort investigation of women undergoing prepectoral pocket conversion. Pre-conversion clinical characteristics and surgical complications (major and minor) were collected. Predictors for postoperative complications were identified using univariate and multivariate logistic regression models. Odds ratios (OR) and adjusted odds ratios (aOR) are presented with 95% confidence intervals, and p-values were assessed at alpha=0.05.RESULTS: A total of 34 patients (63 breasts) were included. Pocket conversion relieved animation deformity in all breasts. The overall rates of major and minor complications were 14.3% (n=9/63) and 34.9% (n=22/63), respectively, by mean follow-up of 11.1 months. After adjusting for confounders, pre-conversion implant rupture (OR= 6.00, CI= 0.99-34.58; aOR= 12.8, CI= 1.15-170.32) and duration of implant placement (OR=1.35, CI= 1.07-1.78; aOR= 1.1, CI= 1.00-1.21) were found to be significant predictors of major postoperative complications.CONCLUSION: With a fairly inclusive patient population, this series provides data for improved risk stratification of patients considering conversion to relieve animation deformity. Interestingly, traditional risk factors (namely, body mass index and smoking status) were not significant predictors for postoperative complications, suggesting that conversion may be safe in high-risk patients. Such data support more informed preoperative counseling and wider application of this procedure.

    View details for DOI 10.1016/j.bjps.2022.11.014

    View details for PubMedID 36592536

  • Travel Distance and National Access to Gender-Affirming Care Thawanyarat, K., Johnstone, T., Rowley, M., Eggert, G., Morrison, S., Nazerali, R. LIPPINCOTT WILLIAMS & WILKINS. 2022: S212
  • Autologous reconstruction for partial mastectomy defects: outcomes of latissimus versus abdominal flaps EUROPEAN JOURNAL OF PLASTIC SURGERY Patel, A. A., Henn, D., Pires, G., Beniwal, A., Rowley, M. A., Lee, G. K., Nazerali, R. S. 2022
  • Improving preclinical medical student's perception of plastic and reconstructive surgery EUROPEAN JOURNAL OF PLASTIC SURGERY Singh, D., Deptula, P., Cheng, J., Rowley, M., Thawanyarat, K., Said, H., Parsa, F., Nazerali, R. 2022
  • Transversus abdominus plane blocks do not reduce rates of postoperative prolonged opioid use following abdominally based autologous breast reconstruction: a nationwide longitudinal analysis. European journal of plastic surgery Chattopadhyay, A., Shah, J. K., Yesantharao, P., Ho, V. T., Sheckter, C. C., Nazerali, R. 2022: 1-11

    Abstract

    Background: The transversus abdominus plane (TAP) block reduces postoperative donor site pain in patients undergoing autologous breast reconstruction with an abdominally based flap. This study aimed to determine the effect of TAP blocks on rates of conversion to chronic opioid use.Methods: The Clinformatics Data Mart was queried from 2003 to 2019, extracting adult encounters for abdominally based free and pedicled flaps based on common procedural terminology (CPT) codes. Patients were excluded if they had filled a narcotic prescription 1 year to 30 days prior to surgery. The exposure variable-TAP block-was identified by CPT codes. Outcomes were evaluated using morphine milligram equivalents (MME) from prescriptions filled between 30 days prior to and 30 days after surgery. Chronic opioid use (COU) was defined as receiving 4 unique prescriptions or a 60-day supply between 30 and 180 days after surgery.Results: Of the 4091 patients, (mean age 51.2±9.0 years), 181 (4.4%) had a TAP block placed. Perioperative MMEs/day, postoperative COU, and length of stay did not differ in patients who received a TAP block (p=0.142; p=0.271). Significant predictors of risk of conversion to COU included younger age, pedicled abdominal flap, Elixhauser comorbidity index score>3, filling a psychiatric medication prescription, and filling a benzodiazepine prescription.Conclusions: In patients undergoing autologous breast reconstruction with abdominally based flap reconstruction, TAP blocks do not decrease perioperative MME/day, conversion to chronic opioid use, or length of stay. These data suggest that intraoperative TAP block placement may be a low-yield opioid-reduction strategy.Level of evidence: Level III, risk/prognostic study.

    View details for DOI 10.1007/s00238-022-01996-5

    View details for PubMedID 36212234

  • Breast reconstruction using the Latissimus Dorsi Flap and Immediate Fat Transfer (LIFT): A systematic review and meta-analysis. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Escandon, J. M., Escandon, L., Ahmed, A., Weiss, A., Nazerali, R., Ciudad, P., Langstein, H. N., Manrique, O. J. 2022

    Abstract

    BACKGROUND: Despite several efforts have been made to increase the volume of the latissimus dorsi (LD) flap, few studies have reported the outcomes of LD flap and immediate fat transfer (LIFT) to restore a natural native breast appearance during the initial reconstructive procedure. The aim of this study was to report the different surgical techniques used when implementing LIFT for breast reconstruction and evaluate the postoperative outcomes.METHODS: A systematic search was conducted across PubMed, Embase, Web of Science, Ovid MEDLINE, and Scopus. We included articles reporting postoperative outcomes of patients who underwent breast reconstruction with LIFT.RESULTS: We included nineteen studies reporting outcomes of 704 breast reconstructions with LIFT (57.09%). The average age and BMI of patients were 51 years and 26.01kg/m2. The pooled rate of patients requiring additional fat grafting following LIFT was 64.9% (95% CI 43.3%-86.5%). The overall pooled incidence of total flap loss was 3% (95% CI <0%-7.2%), wound-related complications was 14.5% (95% CI 7.3%-21.7%), seroma was 18.2% (95% CI 5.1%-31.2%), and fat necrosis was 14.5% (95% CI 4.5%-24.4%). When compared with abdominal free flaps, we found a significantly lower risk difference of developing wound-related complications favoring LIFT (RD, 0.066; 95%CI 0.004-0.129; p=0.038).CONCLUSIONS: LIFT offers a totally autologous, less morbid type of reconstruction in breast cancer patients who are not ideal candidates for reconstruction with free tissue transfer. However, immediate fat transfer during reconstruction with the LD flap does not eliminate the need for further fat grafting.

    View details for DOI 10.1016/j.bjps.2022.08.025

    View details for PubMedID 36241504

  • Minimally Invasive Harvest of the Latissimus Dorsi Flap for Breast Reconstruction: A Systematic Review. The international journal of medical robotics + computer assisted surgery : MRCAS Escandon, J. M., Nazerali, R., Ciudad, P., Lo Torto, F., Maruccia, M., Butterfield, J. A., Vizcay, M., Galan, N., Manrique, O. J. 2022: e2446

    Abstract

    BACKGROUND: Poor cosmetic results with oncoplastic and implant-based breast reconstruction have stimulated an interest in latissimus dorsi flap (LDF)-based reconstruction. We reviewed the surgical techniques and outcomes of the LDF harvested with minimally invasive surgery.METHODS: A systematic search was conducted across PubMed-MEDLINE, Web of Science, Scopus, and Ovid-MEDLINE(R). Data on surgical outcomes were extracted.RESULTS: Thirty-one articles were included reporting on 857 reconstructive procedures using a LDF harvested, 497 were endoscopic-assisted LDF (EALDF)(58%) and 174 were robotic-assisted LDF (RALDF)(20.3%). The average flap harvest time was 84.04-min for EALDF and 106.14-min for RALDF. With an EALDF, the incidence of hematoma, seroma, and wound dehiscence ranged between 0%-16.6%, 0%-48%, and 0-6.2%, respectively. Using RALDF, the incidence of seroma was between 0-26.1% and 0-3.4% for hematoma.CONCLUSIONS: While the indications for a LDF harvested with MIS are limited, its main advantage for breast reconstruction is the absence of the back scar. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/rcs.2446

    View details for PubMedID 35975324

  • Smooth versus textured tissue expanders in breast reconstruction - A retrospective review of post-operative surgical site infections. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Tevlin, R., Cemaj, S. L., Azad, A. D., Borrelli, M. R., Silverstein, M. L., Posternak, V., Nguyen, D., Lee, G. K., Nazerali, R. S. 2022

    Abstract

    Textured tissue expanders (TTEs) were introduced to limit migration and reduce capsular contracture, which were inherent to smooth tissue expanders (STEs). Previous reports suggest that textured devices have increased rates of bacterial contamination and biofilm formation in comparison with smooth devices. Recently, the relative increased association of anaplastic large cell lymphoma (ALCL) with textured versus smooth devices has led to increased adoption of smooth devices. The aim of our study is to evaluate the post-operative surgical site infection (SSI) rates of STEs versus TTEs.A retrospective case series was conducted at a single academic teaching hospital from April 2016 to December 2019. The primary outcome variable was the development of a post-operative SSI.One hundred seventy-seven breasts underwent reconstruction with TTEs and 109 breasts underwent reconstruction with STE. In total, 54 SSIs were recorded (n = 34 TTE; n = 20 STE), with the majority of infections occurring within the first 30 post-operative days (TTE 65%, STE 70%). There was no statistically significant difference in overall post-operative infection rates between TTE and STE groups when broken down into the following time points: <30 day, 30-60 days, and >90 days (p = 0.924). There was no statistically significant difference between infection type (superficial vs. deep, p = 0.932), infection management (medical, surgical, or both, p = 0.409) or salvage results (p = 0.078) seen in STE versus TTE cohort. On multivariate analysis, seroma history was associated with SSI development (OR 3.18, p = 0.041).There was no significant difference in the rate of post-operative SSI following breast reconstruction with STE relative to TTE.

    View details for DOI 10.1016/j.bjps.2022.04.087

    View details for PubMedID 35768293

  • Air versus Saline: The Effect of Tissue Expander Fill on Outcomes of Prepectoral Breast Reconstruction. Plastic and reconstructive surgery Yesantharao, P. S., Rizk, N., Martin, S. A., Tevlin, R., Lee, G. K., Nazerali, R. S. 2022

    Abstract

    BACKGROUND: Traditionally, saline is used for intraoperative/postoperative expansion in two-stage alloplastic breast reconstruction. Recently, intraoperative expansion with air has been proposed, to reduce pressure on the mastectomy skin flap in the immediate postoperative setting. The authors examined whether the intraoperative tissue expansion medium (i.e., air versus saline) affected postmastectomy complications in two-stage prepectoral reconstruction.METHODS: This was a retrospective cohort study of 87 patients (144 breasts) undergoing prepectoral breast reconstruction at the authors' institution. Patient data were abstracted from medical records. Stepwise, multivariable-adjusted logistic regression using robust variances was used to identify predictors of postmastectomy complications. Statistical and power analyses were completed.RESULTS: Of the 87 study patients, 29 (33.3 percent) received intraoperative saline fill and 58 (66.7 percent) received air fill. Demographic/clinical data were well-matched between cohorts. Median follow-up was 165 days, and average patient age was 46.7 years. Initial tissue expander fill volumes were similar between study cohorts (p = 0.2). The crude association between air versus saline fill on overall complication rates suggested that air-filled tissue expanders may be protective (OR = 0.4; p = 0.03), and the suggested protective effect was maintained with borderline significance even after potential confounders (i.e., American Society of Anesthesiologists class III or higher, body mass index, diabetes, mastectomy specimen weight, smoking status) were added to the model (OR = 0.4; p = 0.05). In addition, fewer complications requiring salvage reoperation were observed with air-filled tissue expanders (adjusted OR = 0.3; p = 0.02).CONCLUSIONS: The medium used for immediate intraoperative tissue expansion impacted postmastectomy outcomes in patients undergoing two-stage prepectoral breast reconstruction. The results demonstrated that air-filled tissue expanders were associated with fewer postoperative complications/salvage reoperations relative to saline-filled tissue expanders.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

    View details for DOI 10.1097/PRS.0000000000009191

    View details for PubMedID 35499585

  • Eleventh Dedicated California Society of Plastic Surgeons Annals of Plastic Surgery Supplement. Annals of plastic surgery Nazerali, R. S., Reid, C. 2022; 88 (4 Suppl 4): S315

    View details for DOI 10.1097/SAP.0000000000003225

    View details for PubMedID 37740464

  • Fat Grafts Augmented With Vitamin E Improve Volume Retention and Radiation-Induced Fibrosis. Aesthetic surgery journal Abbas, D. B., Lavin, C. V., Fahy, E. J., Griffin, M., Guardino, N. J., Nazerali, R. S., Nguyen, D. H., Momeni, A., Longaker, M. T., Wan, D. C. 2022

    Abstract

    Treatments for radiation-induced fibrosis range from vitamin E and pentoxifylline systemically to deferoxamine and fat grafting locally. Regarding fat grafting, volume retention hinders its long-term functionality and is affected by two factors: inflammation and necrosis secondary to hypovascularity.We aimed to simultaneously improve fat graft retention and radiation-induced fibrosis by integrating vitamin E and pentoxifylline into fat grafts locally.Forty adult CD-1 nude male mice at 6 weeks of age underwent scalp irradiation and recovered for four weeks to allow for the development of fibrosis. Mice received 200μL of donor human fat graft to the scalp. Mice were separated into 4 conditions: no grafting, fat graft without treatment, graft treated with pentoxifylline, and graft treated with vitamin E. Fat graft volume retention was monitored in-vivo using microCT scans at weeks 0, 1, 2, 4, 6, and 8 after grafting. Histological and cytokine analysis of the scalp skin and fat grafts were also performed.Vitamin E (VE) treated grafts had significant improvement in dermal thickness and collagen density of overlying skin compared to all other groups. VE decreased 8-isoprostane and increased CD31 + staining compared to the other grafted groups. Cytokine analysis revealed decreased inflammatory and increased angiogenic markers in both the fat graft and overlying skin of the vitamin E group. Fat graft volume retention was significantly improved in the vitamin E group starting at 1 week post grafting.Radiation-induced fibrosis and fat graft volume retention are both simultaneously improved with local administration of vitamin E.

    View details for DOI 10.1093/asj/sjac066

    View details for PubMedID 35350074

  • The Price of Publishing: An Investigation of the Open Access Landscape in Plastic Surgery. Plastic and reconstructive surgery Yesantharao, P. S., Long, C., Sacks, J. M., Lee, G. K., Nazerali, R. S. 2022

    Abstract

    BACKGROUND: Open access publishing in plastic surgery has rapidly gained traction in the past decade. This study investigated the digital landscape of plastic surgery open access publishing.METHODS: This was a cross-sectional bibliometric investigation of plastic surgery-focused journals. Three publication models were investigated: subscription-only journals, hybrid journals offering both paywalled and open access publishing, and open access-only journals.RESULTS: Eighty-two journals were investigated. In 2010, open access journals comprised 18 percent of all plastic surgery journals online, subscription journals comprised 79 percent, and hybrid journals comprised 3 percent. Conversely, in 2020, open access journals comprised 55 percent of all journals, hybrid journals comprised 45 percent, and there were no subscription-only journals. Multivariable linear regression adjusting for article type/content demonstrated that open access articles from hybrid journals [beta coefficient, 1.3; F(4, 18) = 790; p = 0.05] and high-quality open access journals [beta coefficient, 0.9; F(4, 19) = 738; p = 0.04] were significantly positively associated with number of full-text views. Although impact factor and article processing charges were positively correlated [Pearson correlation coefficient: r(25) = 0.39, p = 0.04] for open access publishing, some high-quality open access journals were found to offer fee waivers/free publishing. Lastly, level of evidence offered by articles from open access versus hybrid journals differed.CONCLUSIONS: Overall, this study highlighted important distinctions between trustworthy and predatory journals offering open access publishing in plastic surgery. Open access publishing in trustworthy sources offers greater visibility and is not necessarily cost-prohibitive, but some open access journals can be limited in scope (i.e., less coverage of subspecialty topics) and quality of content. Study findings were used to generate recommendations for navigating open access publishing in plastic surgery.

    View details for DOI 10.1097/PRS.0000000000009016

    View details for PubMedID 35311801

  • Vitamin E Treated Fat Grafts Demonstrate Improved Volume Retention And Decreased Radiation-Induced Fibrosis Abbas, D. B., Lavin, C. V., Fahy, E. J., Lintel, H., Griffin, M., Nazerali, R., Dung Nguyen, Momeni, A., Longaker, M. T., Wan, D. WILEY. 2022: A16
  • Labiaplasty and Insurance: To Cover or Not to Cover? Archives of plastic surgery Rowley, M., Thawanyarat, K., Shah, J., Nazerali, R. 2022; 49 (2): 285-286

    View details for DOI 10.1055/s-0042-1744428

    View details for PubMedID 35832678

    View details for PubMedCentralID PMC9045511

  • Labialasty and Insurance: To Cover or Not to Cover? ARCHIVES OF PLASTIC SURGERY-APS Rowley, M., Thawanyarat, K., Shah, J., Nazerali, R. 2022; 49 (02): 285-286
  • Combining Breast and Ovarian Operations Increases Complications. Plastic and reconstructive surgery Henn, D., Barrera, J. A., Sivaraj, D., Lin, J. Q., Rizk, N. M., Ma, I., Gurtner, G. C., Lee, G. K., Nazerali, R. S. 2022

    Abstract

    Breast cancer resulting from a genetic mutation, such as BRCA1 or BRCA2, is seen in 5 to 10 percent of patients. More widespread genetic testing has increased the number of affected women undergoing prophylactic mastectomy and oophorectomy. Recent studies have yielded mixed results regarding complication rates after combined breast and ovarian operations. The authors compared surgical outcomes of breast operations performed in combination with salpingo-oophorectomies or as separate procedures.The authors retrospectively analyzed surgical complications and length of hospital stay in 145 female patients, from which 87 had undergone combined breast surgery and salpingo-oophorectomy, and 58 had undergone these procedures separately. Multivariate logistic regression models were used to calculate odds ratios and 95 percent confidence intervals.Patients undergoing combined breast and ovarian operations experienced higher rates of overall complications (46.5 percent versus 19 percent; p < 0.001), infections (22.2 percent versus 8.6 percent; p < 0.05), and delayed wound healing (13.2 percent versus 0 percent; p < 0.05) related to the breast surgery, when compared with patients undergoing separate procedures. Multivariate logistic regression analysis confirmed a significant association between combined surgery and overall postoperative complications (OR, 5.87; 95 percent CI, 2.03 to 16.91; p = 0.02). Patients undergoing tissue expander-based breast reconstruction combined with ovarian surgery had significantly longer hospital stays compared to patients undergoing separate procedures (3.5 days versus 1.8 days; p < 0.001).The authors' data indicate that combining breast and ovarian operations is associated with a higher risk of postoperative complications related to the breast procedure and increases the duration of hospital stay in patients with tissue expander-based reconstructions. The authors' study provides valuable information for preoperative counseling of patients considering both breast and ovarian surgery.Therapeutic, III.

    View details for DOI 10.1097/PRS.0000000000008984

    View details for PubMedID 35245249

  • Reinforced Biologic Mesh Reduces Postoperative Complications Compared to Biologic Mesh after Ventral Hernia Repair. Plastic and reconstructive surgery. Global open Sivaraj, D., Henn, D., Fischer, K. S., Kim, T. S., Black, C. K., Lin, J. Q., Barrera, J. A., Leeolou, M. C., Makarewicz, N. S., Chen, K., Perrault, D. P., Gurtner, G. C., Lee, G. K., Nazerali, R. 2022; 10 (2): e4083

    Abstract

    The use of biologic mesh to reinforce the abdominal wall in ventral hernia repair has been proposed as a viable alternative to synthetic mesh, particularly for high-risk patients and in contaminated settings. However, a comparison of clinical outcomes between the currently available biologic mesh types has yet to be performed.We performed a retrospective analysis of 141 patients who had undergone ventral hernia repair with biologic mesh, including noncross-linked porcine ADM (NC-PADM) (n = 51), cross-linked porcine ADM (C-PADM) (n = 17), reinforced biologic ovine rumen (RBOR) (n = 36), and bovine ADM (BADM) (n = 37) at the Stanford University Medical Center between 2002 and 2020. Postoperative donor site complications and rates of hernia recurrence were compared between patients with different biologic mesh types.Abdominal complications occurred in 47.1% of patients with NC-PADM, 52.9% of patients with C-PADM, 16.7% of patients with RBOR, and 43.2% of patients with BADM (P = 0.015). Relative risk for overall complications was higher in patients who had received NC-PADM (RR = 2.64, P = 0.0182), C-PADM (RR = 3.19, P = 0.0127), and BADM (RR = 2.11, P = 0.0773) compared with those who had received RBOR. Furthermore, relative risk for hernia recurrence was also higher in all other mesh types compared with RBOR.Our data indicate that RBOR decreases abdominal complications and recurrence rates after ventral hernia repair compared with NC-PADM, C-PADM, and BADM.

    View details for DOI 10.1097/GOX.0000000000004083

    View details for PubMedID 35141102

    View details for PubMedCentralID PMC8820910

  • Does Higher Intraoperative Fraction of Inspired Oxygen Improve Complication Rates Following Implant-Based Breast Reconstruction? Aesthetic surgery journal. Open forum Rowley, M. A., Thawanyarat, K., Shah, J. K., Cai, L., Turner, E., Manrique, O. J., Thornton, B., Nazerali, R. 2022; 4: ojac039

    Abstract

    Background: The surgical literature debates about whether an average intraoperative fractional inspired level of oxygen (FiO2) greater than 80% confers lower postsurgical complication rates. Although some evidence demonstrates minimal or no difference in short-term mortality or surgical site infections, few studies suggest negative long-term outcomes.Objectives: To the best of our knowledge, this is the first study examining the relationship between intraoperative FiO2 levels and postoperative outcomes in the setting of immediate prepectoral implant-based breast reconstruction.Methods: The authors retrospectively reviewed the complication profiles of 309 patients who underwent prepectoral 2-stage breast reconstruction following mastectomy between 2018 and 2021 at a single institution. Two cohorts were created based on whether intraoperative FiO2 was greater than 80% or less than or equal to 80%. Complication rates between the cohorts were analyzed using Chi-squared test, Fisher's exact test, and multivariable logistic regressions. Variables examined included demographic information; smoking history; preexisting comorbidities; history of chemotherapy, radiation, or axillary lymph node dissection; and perioperative information.Results: Chi-squared and multivariable regression analysis demonstrated no significant difference between cohorts in complication rates other than reoperation. Reoperation rates were significantly increased in the FiO2 greater than 80% cohort (P = 0.018). Multivariable logistic regression also demonstrated that the use of acellular dermal matrix was significantly associated with increased postoperative complications (odds ratio 11.985; P = 0.034).Conclusions: Complication rates did not statistically differ in patients with varying intraoperative FiO2 levels outside of reoperation rates. In the setting of implant-based prepectoral breast reconstruction, hyperoxygenation likely does not lead to improved postsurgical outcomes.Level of Evidence 3:

    View details for DOI 10.1093/asjof/ojac039

    View details for PubMedID 35662907

  • Single Institution's Plastic Surgery Case Trends and Considerations in the Midst of COVID-19. Plastic and reconstructive surgery Ma, I. T., Dayani, F., Yesantharao, P., Chang, J., Hawn, M. T., Wald, S., Lee, G. K., Nazerali, R. 2021

    View details for DOI 10.1097/PRS.0000000000008657

    View details for PubMedID 34878421

  • Dress to Impress: Public Perception of Plastic Surgeon Attire. Aesthetic surgery journal Dayani, F., Thawanyarat, K., Mirmanesh, M., Spargo, T., Saia, W., Nazerali, R. 2021

    Abstract

    BACKGROUND: Physician attire has been shown to impact patients' perceptions of their provider with regards to professionalism, competency, and trustworthiness in various surgical subspecialties, except in plastic and reconstructive surgery.OBJECTIVES: This study aims to address this knowledge gap and obtain objective information regarding patients' preferences.METHODS: A survey was distributed to adult, English-speaking participants in the U.S. using Amazon MTurk platform from February 2020 to December 2020. Participants were asked to evaluate six attires (scrubs, scrubs w/ white coat, formal attire, formal attire w/ white coat, casual, casual w/ white coat) in terms of professionalism, competency, and trustworthiness for male and female plastic surgeons during their first encounter in clinic using a 5-point Likert scale.RESULTS: A total of 316 responses were obtained, which consists of 43.4% men and 56.6% women. Mean age of participants was 53.2 years. The highest scores across all metrics of professionalism, competency, trustworthiness, willingness to share information, confidence in the provider, and confidence in surgical outcomes were given to the formal attire with white coat group with average scores of 4.85, 4.71, 4.69, 4.73, 4.79, 4.72, respectively. The lowest scores across all metrics belonged to the casual attire group with scores of 3.36, 3.29, 3.31, 3.39, 3.29, 3.20, respectively. Patients preferred formal attires for young plastic surgeons (p=0.039).CONCLUSIONS: Our study suggests that physician attire impacts patients' perception of plastic surgeons with regards to their professionalism, competency, and trustworthiness. White coats continue to remain a powerful entity in clinical settings given that attires with white coats were consistently ranked higher.

    View details for DOI 10.1093/asj/sjab408

    View details for PubMedID 34849557

  • The Plane of Mesh Placement Does Not Impact Abdominal Donor Site Complications in Microsurgical Breast Reconstruction. Annals of plastic surgery Henn, D., Sivaraj, D., Barrera, J. A., Lin, J. Q., Chattopadhyay, A., Maan, Z. N., Chen, K., Nguyen, A., Cheesborough, J., Gurtner, G. C., Lee, G. K., Nazerali, R. 2021; 87 (5): 542-546

    Abstract

    BACKGROUND: Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated.METHODS: We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88).RESULTS: Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications.CONCLUSIONS: Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps.

    View details for DOI 10.1097/SAP.0000000000002897

    View details for PubMedID 34699433

  • The Impact of Plastic Surgeon Attire on Patient Perceptions Dayani, F., Thawanyarat, K., Nazerali, R. ELSEVIER SCIENCE INC. 2021: S211
  • Autologous and Implant-Based Breast Reconstruction Outcomes in Patients with Autoimmune Connective Tissue Diseases Khan, S. I., Yesantharao, P. S., Rowley, M., Shah, J. K., Rogers, A. B., Nazerali, R. ELSEVIER SCIENCE INC. 2021: S204
  • Decellularized Adipose Matrices can Alleviate Radiation-induced Skin Fibrosis. Advances in wound care Adem, S., Abbas, D. B., Lavin, C., Fahy, E., Griffin, M., Diaz Deleon, N. M., Borrelli, M. R., Mascharak, S., Shen, A. H., Patel, R. A., Longaker, M. T., Nazerali, R. S., Wan, D. C. 2021

    Abstract

    OBJECTIVE: Radiation therapy is commonplace for cancer treatment but often results in fibrosis and atrophy of surrounding soft tissue. Decellularized adipose matrices (DAMs) have been reported to improve these soft tissue defects through the promotion of adipogenesis. These matrices are decellularized by a combination of physical, chemical, and enzymatic methods to minimize their immunologic effects while promoting their regenerative effects. In this study, we aimed to explore the regenerative ability of a DAM (Renuva, MTF Biologics, New Jersey, USA) in radiation-induced soft tissue injury.APPROACH: Fresh human lipoaspirate or DAM was injected into the irradiated scalp of CD-1 nude mice, and volume retention was monitored radiographically over 8 weeks. Explanted grafts were histologically assessed, and overlying skin was examined histologically and biomechanically. Irradiated human skin was also evaluated from patients following fat grafting or DAM injection. However, integrating data between murine and human skin in all cohorts is limited given the genetic variability between the two species.RESULTS: Volume retention was found to be greater with fat grafts, though DAM retention was nonetheless appreciated at irradiated sites. Improvement in both mouse and human irradiated skin overlying fat and DAM grafts was observed in terms of biomechanical stiffness, dermal thickness, collagen density, collagen fiber networks, and skin vascularity.INNOVATION: This is the first demonstration of the use of DAMs for augmenting the regenerative potential of irradiated mouse and human skin.CONCLUSIONS: These findings support use of DAMs to address soft tissue atrophy following radiation therapy. Morphological characteristics of the irradiated skin can also be improved with DAM grafting.

    View details for DOI 10.1089/wound.2021.0008

    View details for PubMedID 34346243

  • Masking Gender: The Impact of Facial Coverings on Gender Recognition. Plastic and reconstructive surgery Simon, D., Capitan, L., Martin, S. A., Nazerali, R., Satterwhite, T., Morrison, S. D., Capitan-Canadas, F. 2021

    View details for DOI 10.1097/PRS.0000000000008273

    View details for PubMedID 34346914

  • Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze? Aesthetic plastic surgery Martin, S. A., Patel, V., Morrison, S. D., Kahn, D., Satterwhite, T., Nazerali, R. 2021

    Abstract

    BACKGROUND: Outcomes of gender-affirming chest surgery can be variable. Placement of nipple-areolar complexes and orientation of scars can drastically affect the aesthetic outcomes of these procedures, as may observer gender identity. Here, we compared attention and perception of outcomes following gender-affirming chest surgery between laypersons, based on gender identity.METHODS: Transgender and cisgender participants were enrolled and shown images of surgery naive chests and postoperative masculinized and feminized chests, blinded to the gender identity of the photographed subject. Gaze data were captured using the Tobii X2 60 eye-tracking device. Participants scored the perceived gender and aesthetic appearance of each image.RESULTS: Eighteen cisgender and 14 transgender participants were enrolled. When viewing male chests, transgender participants spent significantly longer fixated on the nipples (naive: 802 vs. 395ms; p=0.02, masculinized: 940 vs. 692ms, p=0.002). For masculinized chests, cisgender participants spent significantly longer fixated on the inframammary scar (483 vs. 391ms; p=0.04). On images of feminized chests, transgender participants spent longer viewing the nipples when compared to cisgender participants (1017 vs. 847ms; p=0.04). Cisgender viewers spent longer fixating on the postoperative scar on feminized chests (113 vs. 59ms; p=0.02) and also viewed feminized chests as significantly more masculine and masculinized chests as more feminine, when compared to transgender participants (p<0.05).CONCLUSIONS: This is the first study to use eye-tracking to assess how laypersons assess chests for gender determination. The findings suggest that observer gender identity has an effect on areas of focus and gender perception of chests that underwent gender-affirmation surgery.LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

    View details for DOI 10.1007/s00266-021-02378-1

    View details for PubMedID 34114074

  • Tenth Dedicated CSPS Annals. Annals of plastic surgery Nazerali, R., Reid, C. 2021; 86 (5S Suppl 3): S353

    View details for DOI 10.1097/SAP.0000000000002914

    View details for PubMedID 33976065

  • Comparing Outcomes of Flap-Based Salvage Reconstructions in the Radiated Breast. Annals of plastic surgery Patel, A. A., Arquette, C. P., Rowley, M. A., Borrelli, M. R., Lee, G. K., Nazerali, R. S. 2021; 86 (5S Suppl 3): S403–S408

    Abstract

    INTRODUCTION: Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts.METHODS: Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected.RESULTS: A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069).CONCLUSIONS: When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.

    View details for DOI 10.1097/SAP.0000000000002761

    View details for PubMedID 33976069

  • Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction. Annals of plastic surgery Patel, A. A., Arquette, C. P., Yesantharao, P. S., Borrelli, M. R., Broderick, K. P., Cheesborough, J. E., Lee, G. K., Nazerali, R. S. 2021; 86 (5S Suppl 3): S390–S394

    Abstract

    BACKGROUND: Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane.METHODS: A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications.RESULTS: A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870).CONCLUSIONS: Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

    View details for DOI 10.1097/SAP.0000000000002762

    View details for PubMedID 33976068

  • Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery Brown-Johnson, C. G., Spargo, T., Kling, S. M., Saliba-Gustafsson, E. A., Lestoquoy, A. S., Garvert, D. W., Vilendrer, S., Winget, M., Asch, S. M., Maggio, P., Nazerali, R. S. 2021

    Abstract

    BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n= 20) and surgeons (n= 10) to explore stakeholder perspectives on video visits.RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

    View details for DOI 10.1016/j.surg.2021.03.029

    View details for PubMedID 33941389

  • Response to: "Commentary on Delayed, two-staged autologous breast reconstruction: an approach to improving delayed reconstructive outcomes" by Mantelakis A, Kazzazi D, Bloom O, Gallagher M, Weale R & Geh J EUROPEAN JOURNAL OF PLASTIC SURGERY Patel, A. A., Cai, L., Moshrefi, S., Sando, I. C., Lee, G. K., Nazerali, R. S. 2021
  • Revision Rates in Prepectoral Versus Subpectoral Delayed-Immediate Autologous Breast Reconstruction. Annals of plastic surgery Patel, A. A., Cemaj, S. L., Martin, S. A., Cheesborough, J. E., Lee, G. K., Nazerali, R. S. 2021

    Abstract

    INTRODUCTION: Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions.METHODS: Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions.RESULTS: Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034).CONCLUSIONS: Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.

    View details for DOI 10.1097/SAP.0000000000002760

    View details for PubMedID 33833169

  • Autologous Fat Grafting and the Occurrence of Radiation-Induced Capsular Contracture. Annals of plastic surgery Martin, S., Cai, L., Beniwal, A., Tevlin, R., Lee, G., Nazerali, R. S. 2021

    Abstract

    INTRODUCTION: Radiation therapy is a known risk factor for capsular contracture formation after implant-based breast reconstruction. Although autologous fat grafting (AFG) has been shown to reverse radiation-induced tissue fibrosis, its use as a prophylactic agent against capsular contraction has not been assessed in the clinical setting. In the setting of 2-stage implant-based reconstruction and postmastectomy radiation therapy, we explored the effect AFG has on the prevalence of capsular contracture.MATERIALS AND METHODS: A retrospective chart review of patients who underwent immediate tissue expander (TE) placement followed by postmastectomy radiation therapy and secondary implant-based reconstruction at our institution between January 2012 and December 2019 was performed. Patients were divided into 2 cohorts based on whether or not AFG was performed at the time of secondary reconstruction. The primary outcome of interest was the occurrence of capsular contracture after TE exchange.RESULTS: Overall 57 patients (57 breasts) were included, 33 of whom received AFG at the time of TE exchange. All but 1 patient underwent submuscular implant placement, and the mean follow-up was 1.96 years. There was no significant difference in the prevalence of medical comorbidities between the study groups.Capsular contracture occurred in 24 patients (42.1%). Seventeen of these patients had undergone AFG at the time of TE exchange (17/33 patients, 51.5%), and 7 of these patients had not (7/24 patients, 29.2%). Most of the capsular contracture cases were Baker grades III or IV (14 patients, 58.3%), and 50% of patients with capsular contracture of any grade ultimately required operative intervention. Multivariate logistic regression analysis demonstrated that AFG did not significantly influence the occurrence or severity of capsular contracture, or did not impact the need for operative intervention in this patient population.CONCLUSIONS: Implant-based reconstruction of the irradiated breast is associated with high postoperative capsular contracture rates. Although AFG has shown promise in reversing radiation-induced dermal fibrosis, no protective effect on the development of capsular contracture after stage 2 reconstruction was observed in this study population. Further investigation in the form of randomized, prospective studies is needed to better assess the utility of AFG in preventing capsular contracture in irradiated patients.

    View details for DOI 10.1097/SAP.0000000000002817

    View details for PubMedID 33833172

  • Assessing abdominoplasty aesthetics in women with eye-tracking technology-do patients see things differently? EUROPEAN JOURNAL OF PLASTIC SURGERY Peterson, D. J., Gkorila, A., Azad, A. D., Patel, A. A., Boudreault, D. J., Nazerali, R. S. 2021
  • System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection. Plastic and reconstructive surgery Dayani, F., Sheckter, C. C., Rochlin, D. H., Nazerali, R. S. 2021

    Abstract

    Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection.Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction.The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI,1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05).Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction.Risk, III.

    View details for DOI 10.1097/PRS.0000000000008661

    View details for PubMedID 34813526

  • The Zoom Effect: A Google Trends Analysis. Aesthetic surgery journal Thawanyarat, K., Francis, S., Kim, T., Arquette, C., Morrison, S., Nazerali, R. 2021

    Abstract

    Increased video-chatting, stimulated by the COVID-19 pandemic, has been correlated with increased appearance concerns. Initial lockdown restrictions correlated with a decrease in aesthetic/cosmetic plastic surgery case volumes.We aim to delineate public interest in aesthetic procedures surrounding the COVID-19 pandemic via Google Trends (GT). We hypothesize that because of the pandemic, public interest in plastic surgery procedures increased, especially localized above the shoulder.Trends in the US for given search terms and volumes were gathered via Google Trends between January 2015 to March 2021. The search volumes were normalized, and a bivariate regression analysis of panel data was then applied to the aggregate trendlines to determine if a statistically significant change in search volume occurred following the stay-at-home orders.The following search terms had statistically significant (p < 0.000) increases in search volumes after February 2020: blepharoplasty, Botox, brachioplasty, breast implant removal, breast reduction, brow lift, buccal fat removal, hair transplantation, lip augmentation, mentoplasty, otoplasty, platysmaplasty, rhinoplasty, and thighplasty. Chi-squared analysis demonstrated a statistically significant association (Chi-squared = 4.812, p = 0.028) between increases in search volume and above the shoulder procedures.Public interest in above the shoulder surgical procedures showed a statistically significant increase following February 2020 compared to below the shoulder procedures. Continued examination of specific procedure trends, as well as determining correlations with more accurate procedural datasets, will provide increased insight into consumers' mindsets and to what extent video conferencing plays on the public's interest in pursuing aesthetic surgery.

    View details for DOI 10.1093/asj/sjab347

    View details for PubMedID 34581762

  • Reply: Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Kwong, J. W., Azad, A. D., Kahn, D., Lee, G. K., Nazerali, R. S. 2020; 146 (6): 821e-822e

    View details for DOI 10.1097/PRS.0000000000007375

    View details for PubMedID 33234991

  • 'What is Your Reality? - Virtual, Augmented, and Mixed Reality in Plastic Surgery Training, Education, and Practice '. Plastic and reconstructive surgery Lee, G., Moshrefi, S., Fuertes, V., Veeravagu, L., Nazerali, R., Lin, S. J. 2020

    Abstract

    Virtual reality and other technological advancements both inside and outside the operating room have shown an exponential increase in the past two decades. Surgical techniques and finesse in delicate procedures has become ever more important and the onus is on plastic surgeons and plastic surgery residents to meet these needs to provide the best outcomes possible to patients. The ability to learn, simulate, and practice operating in a fashion that poses no harm to any patient is truly a gift from technology to surgery that any surgeon could benefit from, whether trainee or attending. This application of technology and simulation has been demonstrated in other fields such as in the airline industry with flight simulation. The ability to learn, synthesize, and incorporate learned materials and ideas through virtual, augmented, and mixed reality tools offers a great opportunity to put our field at the forefront of a paradigm shift in surgical education. The critical utility of digital education could not be further emphasized any more than in the unfortunate and infrequent situation of a world-wide pandemic. This article reviews some of the important recent technologies that have developed and their applications in plastic surgery education and offers a look into what we can expect in the future.

    View details for DOI 10.1097/PRS.0000000000007595

    View details for PubMedID 33235047

  • Single-Unit technique for the use of acellular dermal matrix in immediate expander-based breast reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Luan, A., Patel, A. A., Martin, S. A., Nazerali, R. S. 2020

    Abstract

    BACKGROUND: The use of acellular dermal matrices (ADMs) in immediate two-stage prosthetic breast reconstruction following mastectomy is now a common practice. The procedure confers several compelling benefits, including coverage of the inferior pole, enhanced definition of the inframammary fold, and reduction of capsular contracture. However, operative techniques used to create the ADM inferolateral sling can be unwieldy in practice, typically involving the placement of the ADM followed by positioning and anchoring of the prosthetic expander. At best, this may be a relatively minor nuisance, but may potentially influence outcomes, including discrepancies in symmetry.METHODS: We present a novel modification that aims to streamline this procedure. Perforations are made through the allograft, through which the tissue expander tabs are brought through and sutured together ex vivo to allow the ADM and expander to be placed into the inframammary fold position as a single unit. A retrospective chart review was then performed of patients who underwent breast reconstruction utilizing this technique between July 2015 and December 2018. Outcomes including postsurgical complications such as infection, malposition, and reoperation were analyzed.RESULTS: Sixty-two patients met the inclusion criteria, corresponding to 108 breasts. The average follow-up was 18 months. The overall complication rate was 29.6% of breasts. The most commonly observed complications were mastectomy skin necrosis (9.3%) and major infection (8.3%). There was a 7.4% rate of malposition.CONCLUSIONS: This simple but effective modification in ADM technique is associated with a comparable complication rate and allows for greater ease and consistency in tissue expander placement.

    View details for DOI 10.1016/j.bjps.2020.10.048

    View details for PubMedID 33248935

  • The safety and efficacy of autologous fat grafting during second stage breast reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Patel, A. A., Martin, S. A., Cheesborough, J. E., Lee, G. K., Nazerali, R. S. 2020

    Abstract

    BACKGROUND: Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure.METHODS: We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions.RESULTS: Complication rates were lower when fat grafting was performed during the second stage (p = 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008).CONCLUSIONS: These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries.

    View details for DOI 10.1016/j.bjps.2020.10.008

    View details for PubMedID 33189618

  • Decellularized Adipose Tissue Extracellular Matrices Restore Volume Defects and Promote Regeneration of Irradiated Soft Tissue Borrelli, M. R., Adem, S., Deleon, N., Ngaage, L. M., Momeni, A., Nazerali, R., Wan, D. C. ELSEVIER SCIENCE INC. 2020: E184
  • Postoperative Complication Rates after Combined Breast and Gynecologic Surgeries Rizk, N., Henn, D., Lee, G., Nazerali, R. ELSEVIER SCIENCE INC. 2020: S39–S40
  • Air vs Saline: Effect of Tissue Expander Fill Prepectoral Breast Reconstruction Postoperative Complication Rizk, N., Martin, S., Tevlin, R., Lee, G., Nazerali, R. ELSEVIER SCIENCE INC. 2020: E81
  • Hospital Volume and Type Is Associated with Flap Reconstruction after Abdominoperineal Resection Dayani, F., Sheckter, C., Nazerali, R. ELSEVIER SCIENCE INC. 2020: S226
  • Analysis of Computer Vision Methods for Counting Surgical Instruments. Surgical innovation Chavez, G., Zhao, D., Haque, A., Nazerali, R., Amanatullah, D. F. 2020: 1553350620956425

    View details for DOI 10.1177/1553350620956425

    View details for PubMedID 32877306

  • The Consequences of Delaying Elective Surgery: Surgical Perspective. Annals of surgery Fu, S. J., George, E. L., Maggio, P. M., Hawn, M., Nazerali, R. 2020; 272 (2): e79-e80

    View details for DOI 10.1097/SLA.0000000000003998

    View details for PubMedID 32675504

  • Supplementing fat grafts with Renuva (R) promotes regeneration of irradiated soft tissue Borrelli, M. R., Diaz, N., Adem, S., Spargo, T., Sen, A., Dung Nguyen, Momeni, A., Nazerali, R., Wan, D. C. WILEY. 2020: S62
  • A 20-year tertiary cancer center's experience utilizing the pedicled gracilis myocutaneous flap EUROPEAN JOURNAL OF PLASTIC SURGERY Patel, A. A., Moshrefi, S., Cai, L. Z., Lee, G. K., Nazerali, R. S. 2020
  • Applied Online Crowdsourcing in Plastic and Reconstructive Surgery: A Comparison of Aesthetic Outcomes in Unilateral Cleft Lip Repair Techniques. Annals of plastic surgery Suchyta, M., Azad, A., Patel, A. A., Khosla, R. K., Lorenz, H. P., Nazerali, R. S. 2020; 84 (5S Suppl 4): S307–S310

    Abstract

    BACKGROUND: Aesthetic outcomes of unilateral cleft lip repairs have important psychosocial implications for patients who are heavily influenced by social perceptions. Online crowdsourcing offers the unique potential to efficiently recruit large numbers of laypeople to assess public perception. The aim of this study was to use the online crowdsourcing platform Mechanical Turk to compare the postoperative outcomes of Fisher, Millard, and Mohler cleft lip repair techniques.METHODS: Two hundred fifty-four participants were recruited through Mechanical Turk to evaluate 29 cropped and deidentified photographs of children, 8 photographs were controls without cleft lips and 21 were children with unilateral cleft lips who had undergone Fisher, Millard, or Mohler repairs (7 in each group). Respondents were asked whether a scar was present, whether they would be personally satisfied with the surgical result and used a Likert scale from 1 to 5 to rate overall appearance, scar severity, and nasal symmetry.RESULTS: Fewer respondents reported that a scar was present when assessing postoperative photographs of Fisher repairs (70.3 ± 8.6%) compared with Millard (92.0 ± 1.5%) or Mohler (88.8 ± 3.1%) repairs. Average rating of scar severity was also lower for Fisher (1.9) compared with Millard (2.6) or Mohler (2.6) repairs. Average ratings of nose symmetry, general appearance, and satisfaction with operative result were not statistically significantly different between the repair groups.CONCLUSIONS: This study demonstrates the potential of online crowdsourcing to assess public perception of plastic surgery outcomes. The Mechanical Turk platform offers a reduction in selection bias, ease of study design, and enhanced efficiency of large-scale participant recruitment. Results indicate that the Fisher repair led to the most favored aesthetic outcomes compared with the Millard and Mohler techniques, particularly with regard to scar severity. Crowdsourcing is a powerful tool to assess layperson perception of plastic surgery outcomes and can be used to better guide surgical decision-making.

    View details for DOI 10.1097/SAP.0000000000002389

    View details for PubMedID 32282397

  • Ninth Dedicated CSPS Annals ANNALS OF PLASTIC SURGERY Nazerali, R., Wong, M. S. 2020; 84: S241–S244

    View details for DOI 10.1097/SAP.0000000000002401

    View details for Web of Science ID 000562464200001

    View details for PubMedID 32294073

  • Public Interest in Textured Breast Implants Recall: A Google Trends Analysis. Aesthetic plastic surgery Dayani, F., Tijerina, J. D., Morrison, S. D., Nazerali, R. S. 2020

    Abstract

    BACKGROUND: Large-scale media coverage of health care outcomes can have a profound influence on health care utilization by the general population. Google trends (GT), an online resource, allows for tracking of global search volumes as a proxy for determining public interest.OBJECTIVE: To utilize GT to characterize measurable effects on public interest in breast implant removal procedures and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) following March 2019 FDA Advisory Committee Meeting and July 2019 public statements by the FDA and Allergan announcing the voluntary recall of BIOCELL textured breast implants.METHODS: GT databases of search volumes were collected for terms related to 3 categories including Allergan BIOCELL textured breast implants, BIA-ALCL, and breast implant removal from January 2004 to October 2019. The short-term and long-term interests were determined by the percent change in monthly search volumes with respect to the announcements from Allergan and FDA Advisory Committee Meeting.RESULTS: Following Allergan's recall announcement, public interest in "textured breast implants" and "allergan breast implant" peaked in July 2019 and rose 456%and669%, respectively. Public interest in "anaplastic large cell lymphoma breast implant" and "ALCL cancer" rose 200 and 175%, respectively. Long-term interest in all implant removal terms was found to be higher after March 2019 FDA Advisory Committee Meeting than beforehand (p<0.05).CONCLUSIONS: GT data correlate with shifts in real-world health care utilization and public interest caused by high-profile media coverage, making it a useful tool for providers for real-time prediction of trends in public health in response to observable influences.LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

    View details for DOI 10.1007/s00266-020-01724-z

    View details for PubMedID 32356152

  • The Consequences of Delaying Elective Surgery: Surgical Perspective. Annals of surgery Fu, S. J., George, E. L., Maggio, P. M., Hawn, M., Nazerali, R. 2020

    View details for DOI 10.1097/SLA.0000000000003998

    View details for PubMedID 32355120

  • Delayed, two-staged autologous breast reconstruction: an approach to improving delayed reconstructive outcomes EUROPEAN JOURNAL OF PLASTIC SURGERY Patel, A. A., Cai, L., Moshrefi, S., Sando, I. C., Kee, G., Nazerali, R. S. 2020
  • Google Trends Analyses in Plastic Surgery At Large. Aesthetic surgery journal Tijerina, J. D., Morrison, S. D., Nolan, I. T., Parham, M. J., Nazerali, R. 2020

    View details for DOI 10.1093/asj/sjaa025

    View details for PubMedID 32186682

  • An Evaluation of the Utility of the Breast Reconstruction Risk Assessment Score Risk Model in Prepectoral Tissue Expander Breast Reconstruction. Annals of plastic surgery Martin, S., Turner, E., Nguyen, A., Thornton, B., Nazerali, R. S. 2020

    Abstract

    INTRODUCTION: Individualized postsurgical risk assessment models provide surgeons and patients with information that is vital to the surgical decision-making process. One such tool, the Breast Reconstruction Risk Assessment (BRA) score, uses a limited selection of patient-specific factors to predict 30-day postsurgical risk of surgical site infection, seroma, dehiscence, reoperation and explantation associated with immediate submuscular tissue expander breast reconstruction. This model's performance in prepectoral tissue expander reconstruction has not been previously reported. Here, we evaluate the performance of the BRA score model in a population of patients who underwent immediate prepectoral tissue expander breast reconstruction.MATERIALS AND METHODS: A retrospective chart review was conducted of prepectoral breast reconstructions performed in 2 institutions between January 2017 and December 2018. Complications occurring within 30 days postoperatively were documented and compared with the BRA score predicted risk for each patient.RESULTS: Overall 247 patients (average age, 49.2 years) were included in the study. The mean BRA score predicted 30-day risk of a complication was 13.0% (7.5-41.5%). The observed rate of 30-day postoperative complications was 31.2% (77 patients), though only 36 (14.6%) patients had complications included in the model. The remaining patients experienced skin necrosis or hematoma as their only early complication. The 30-day BRA score model demonstrated good fit for the overall occurrence of any of the BRA score predicted complications (Hosmer-Lemeshow 0.7167), though the model discrimination was poor (C statistic <0.60). Notably, half of the 30-day postsurgical complications observed in this study were due to skin necrosis, a complication not currently included in the 30-day BRA score model.CONCLUSIONS: Our results indicate that the current 30-day BRA score model may have poor predictive value in prepectoral breast reconstruction. The most common early complication observed, skin necrosis, is not currently included in the model, suggesting that caution should be applied when using this risk predictive calculator as an adjunct to patient evaluation and counseling.

    View details for DOI 10.1097/SAP.0000000000002320

    View details for PubMedID 32187065

  • Reply: Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Kwong, J. W., Azad, A. D., Kahn, D. n., Lee, G. K., Nazerali, R. S. 2020; 145 (6): 1104e

    View details for DOI 10.1097/PRS.0000000000006825

    View details for PubMedID 32464032

  • Assessing Gaze Patterns in Common Cosmetic Procedures With Eye-Tracking Technology. Annals of plastic surgery Peterson, D. J., Azad, A. D., Gkorila, A. n., Patel, A. A., Boudreault, M. S., Nazerali, R. S. 2020; 84 (5S Suppl 4): S268–S272

    Abstract

    Understanding the salient features that draw focus when assessing aesthetics is important for maximizing perceived outcomes. Eye-tracking technology provides an unbiased method for determining the features that draw attention when evaluating aesthetic plastic surgery. This study aimed to characterize viewing patterns of plastic surgery patients and laypeople when assessing facial cosmetic procedure images.Twenty women who previously underwent cosmetic procedures and twenty women without a history of cosmetic procedures were shown sixteen pairs of preprocedure and postprocedure images of patients who underwent laser resurfacing or lip augmentation. Image pairs were randomized to whether preprocedural or postprocedural images came first. Participants viewed each image until they decided upon an aesthetic rating (scored 1-10), while an eye-tracking device recorded participants' gaze.The patient group's average ratings were 8.2% higher for preprocedural images and 13.3% higher for postprocedural images (P < 0.05 for both). The patient group spent 20.4% less time viewing images but spent proportionally more time evaluating the relevant features of each procedure (41.7% vs 23.3%, P < 0.01), such as the vermillion border of the upper lip, labial commissure, or periorbital region (P < 0.05 for each). For both groups, the most common site of first fixation was the nose for laser resurfacing images (26.6%) and the labial commissure for lip augmentation images (37.7%). Both groups spent more time fixated on nasolabial folds, marionette lines, and the periorbital region when viewing pre-laser resurfacing images than postprocedural images. Overall, each group had similar viewing patterns for time to first fixation on and frequency of fixations for a particular feature.Women who previously underwent cosmetic procedures view postprocedural images more favorably and require less time to assess images, likely related to familiarity with aesthetic procedures. These women spend more time fixated on relevant features, such as the vermillion border of the upper lip, the labial commissure, and the periorbital region, than the control group. Notably, each group spent less time focused on regions associated with wrinkles, such as the marionette and periorbital areas in post-laser resurfacing images, suggesting that the procedure reduces attention-drawing features in these areas.

    View details for DOI 10.1097/SAP.0000000000002387

    View details for PubMedID 32294074

  • Erratum: Abstract 199: Gender Identity Alters Gaze: The Use of Eye Tracking to Assess Outcomes in Gender-affirming Chest Surgery - Erratum. Plastic and reconstructive surgery. Global open Martin, S. A., Morrison, S. D., Satterwhite, T. n., Nazerali, R. n. 2020; 8 (8): e3106

    Abstract

    [This corrects the article DOI: 10.1097/01.GOX.0000667852.45222.46.].

    View details for DOI 10.1097/GOX.0000000000003106

    View details for PubMedID 32986042

    View details for PubMedCentralID PMC7489693

  • Social Perception of Facial Feminization Surgery Outcomes: Does Gender Identity Alter Gaze? Aesthetic surgery journal Martin, S. A., Morrison, S. D., Patel, V. n., Capitán-Cañadas, F. n., Sánchez-García, A. n., Rodríguez-Conesa, M. n., Bellinga, R. J., Simon, D. n., Capitán, L. n., Satterwhite, T. n., Nazerali, R. n. 2020

    Abstract

    The evaluation of gender-affirming facial feminization surgery (FFS) outcomes can be highly subjective, which has resulted in a limited understanding of the social perception of favorable gender and aesthetic facial appearance following these procedures. The growing use of eye-tracking technology in the assessment of surgical outcomes has introduced an objective measure of viewer subconscious gaze, which may provide more insight into how viewer characteristics may influence gaze, attention and perception of favorable FFS outcomes.In this study, eye-tracking technology was used to measure attention and perception of surgery naïve cisgender female and feminized transgender faces, based on viewer gender identity.Thirty-two participants (18 cisgender and 14 transgender) were enrolled and shown five photos each of surgery naïve cisgender female and feminized transgender faces. Gaze was captured using the Tobii X2 60 eye-tracking device (Tobii, Stockholm, Sweden) and participants rated the gender and aesthetic appearance of each face using Likert-type scales.Total image gaze fixation time did not differ by participant gender identity (6.00 vs 6.04 sec, p = 0.889), however, transgender participants spent more time evaluating the forehead/brow, buccal/mandibular regions and chin (p < 0.001). Multivariate regression analysis showed significant associations between viewer gender identity, age, race, and education and the time spent evaluating gender salient facial features. Feminized faces were rated as more masculine with poorer aesthetic appearance than surgery naïve cisgender female faces, however, there was no significant difference in the distribution of gender appearance ratings assigned to each photo by cisgender and transgender participants.These results demonstrate that gender identity influences subconscious attention and gaze on female faces. Even so, differences in gaze distribution did not correspond to subjective rated gender appearance for either surgery naïve cisgender female or feminized transgender faces, further illustrating the complexity of evaluating social perception of favorable FFS outcomes.

    View details for DOI 10.1093/asj/sjaa377

    View details for PubMedID 33336697

  • Analysis and Interpretation of Google Trends Data on Public Interest in Cosmetic Body Procedures AESTHETIC SURGERY JOURNAL Tijerina, J. D., Morrison, S. D., Nolan, I. T., Vail, D. G., Lee, G. K., Nazerali, R. 2020; 40 (1): NP34–NP43

    View details for DOI 10.1093/asj/sjz051

    View details for Web of Science ID 000562332200007

  • Global Health Microsurgery Training With Cell Phones. Annals of plastic surgery Inchauste, S. M., Deptula, P. L., Zelones, J. T., Nazerali, R. S., Nguyen, D. H., Lee, G. K. 2020; 84 (5S Suppl 4): S273–S277

    Abstract

    Lack of surgical care for trauma, burns, congenital anomalies, and other surgical diseases is a growing portion of global disability and death accounting for 30% of the global disease burden. Global surgical and anesthesia care aim to achieve excellence and equality of clinical care through leadership, innovation, teaching, research, and advocacy. Stanford University Division of Plastic Surgery faculty partnered with ReSurge International to teach reconstructive microsurgery in low- and middle-income countries.Global surgery teaching and training are challenged by limited resources. Surgical loupes and operating microscopes used to perform complex microsurgery magnify the surgical field are very expensive. Our goal was to identify low-cost alternatives to teach and practice microsurgery suturing.Use cell phone camera with zoom capacity to teach and practice microsurgery suturing.Cell phones with zoom feature are widely available even in low- and middle-income countries. A cell phone was placed on a stand over a microsurgery practice station. The camera was used to zoom and focus on the suturing station to mimic a surgical field with loupes or microscope magnification. Nine attending surgeons and 7 residents practiced microsurgery with microsurgical instruments and 9-0 nylon suture under the magnification of a cell phone camera. The Stanford Microsurgery and Resident Training Scale was used to track their progress. A feedback survey was given to the participants to identify the usefulness of the cell phone setup for microsurgery suture practice.Global surgery teaching and training face many challenges especially limited resources. Identifying low-cost alternative is crucial. Cell phone camera with zoom is a low-cost alternative to loupes or operating microscope for microsurgical teaching and training.

    View details for DOI 10.1097/SAP.0000000000002403

    View details for PubMedID 32294075

  • Comparing Prepectoral Versus Subpectoral Tissue Expander Placement Outcomes in Delayed-Immediate Autologous Breast Reconstruction. Annals of plastic surgery Patel, A. A., Borrelli, M. R., Cai, L. n., Moshrefi, S. n., Sando, I. C., Lee, G. K., Nazerali, R. S. 2020; 84 (5S Suppl 4): S329–S335

    Abstract

    Delayed-immediate breast reconstruction has traditionally involved placement of tissue expanders (TE) in the subpectoral (SP) position. Development of acellular dermal matrices has renewed interest in the prepectoral (PP) pocket, which avoids extensive muscle manipulation. We compare complication rates between PP and SP TE placement in autologous delayed-immediate breast reconstruction.A retrospective chart review of patients undergoing autologous, delayed-immediate breast reconstruction at our institution (June 2009 to December 2018) was performed. Demographics, comorbidities, perioperative information, and complication incidence ≤12 months' follow-up were collected from first- and second-stage surgeries. Complications were modeled using univariable and multivariable binary logistic regressions.A total of 89 patients met the inclusion criteria, and data from 125 breast reconstructions were evaluated. Complication rates following TE placement trended lower in the PP cohort (28.8% vs 37%, P = 0.34). Overall complication rates following autologous reconstruction were significantly lower for PP reconstructions (7.7% vs 23.3%, P = 0.02). Multivariable regression showed TE position (P = 0.01) was a significant predictor of ≥1 complication following autologous reconstruction. Time delay between first- and second-stage surgeries was greater for SP reconstructions (199.7 vs 324.8 days, P < 0.001). Postoperative drains were removed earlier in the PP cohort (8.6 vs 12.0 days, P < 0.001). Mean follow-up time was 331.3 days.Prepectoral reconstruction in the delayed-immediate autologous reconstruction patient leads to significantly lower complication rates, shorter duration between first- and second-stage surgeries, and shorter times before removal of breast drains compared with SP reconstructions.

    View details for DOI 10.1097/SAP.0000000000002402

    View details for PubMedID 32294076

  • Assessing the Accuracy of a 3-Dimensional Surface Imaging System in Breast Volume Estimation. Annals of plastic surgery Kwong, J. W., Tijerina, J. D., Choi, S. n., Luan, A. n., Feng, C. L., Nguyen, D. H., Lee, G. K., Nazerali, R. S. 2020

    Abstract

    Preoperative prediction of breast volume can guide patient expectations and aid surgical planning in breast reconstruction. Here, we evaluate the accuracy of a portable surface imager (Crisalix S.A., Lausanne, Switzerland) in predicting breast volume compared with anthropomorphic estimates and intraoperative specimen weights.Twenty-five patients (41 breasts) undergoing mastectomy were scanned preoperatively with the Crisalix surface imager, and 1 of 3 attending plastic surgeons provided an anthropomorphic volume estimate. Intraoperative mastectomy weights were used as the gold standard. Volume conversions were performed assuming a density of 0.958 g/cm.The Pearson correlation coefficient between imager estimates and intraoperative volumes was 0.812. The corresponding value for anthropomorphic estimates and intraoperative volumes was 0.848. The mean difference between imager and intraoperative volumes was -233.5 cm, whereas the mean difference between anthropomorphic estimates and intraoperative volumes was -102.7 cm. Stratifying by breast volume, both surface imager and anthropomorphic estimates closely matched intraoperative volumes for breast volumes 600 cm and less, but the 2 techniques tended to underestimate true volumes for breasts larger than 600 cm. Stratification by plastic surgeon providing the estimate and breast surgeon performing the mastectomy did not eliminate this underestimation at larger breast volumes.For breast volumes 600 cm and less, the accuracy of the Crisalix surface imager closely matches anthropomorphic estimates given by experienced plastic surgeons and true volumes as measured from intraoperative specimen weights. Surface imaging may potentially be useful as an adjunct in surgical planning and guiding patient expectations for patients with smaller breast sizes.

    View details for DOI 10.1097/SAP.0000000000002244

    View details for PubMedID 32032116

  • Angiosarcoma of the Breast: Management and Outcomes. American journal of clinical oncology Gutkin, P. M., Ganjoo, K. N., Lohman, M. n., von Eyben, R. n., Charville, G. W., Nazerali, R. S., Dirbas, F. M., Horst, K. C. 2020

    Abstract

    Angiosarcoma of the breast is rare and has a poor prognosis. We reviewed our institution's experience with this disease to characterize presentation, identify management patterns, and report outcomes.Fifty-eight patients with nonmetastatic angiosarcoma were identified from 1998 to 2019 and retrospectively reviewed. Overall survival (OS) and recurrence-free survival (RFS) were calculated using the Kaplan-Meier analysis and log-rank test.The median follow-up was 43.4 months (range: 1.8 to 203.3 mo). Twenty-four patients had primary angiosarcoma (PAS) and 34 patients had secondary angiosarcoma (SAS). Patients with PAS were significantly younger than those with SAS (P<0.0001). Mastectomy was the main surgical treatment in our cohort (n=47) and 3 underwent a lumpectomy. The multifocal disease was found in 5/23 patients with PAS and 11/35 patients with SAS. Twenty-eight patients received chemotherapy. Radiation was administered to 13 patients with PAS and 3 patients with SAS. Five-year OS was 73.7% for PAS and 63.5% for SAS. Local recurrence occurred in a greater proportion of patients with margins <5 mm than those with margins ≥5 mm. Chemotherapy did not impact RFS and was not associated with OS in PAS (P=0.35). Those with SAS treated with chemotherapy had significantly greater OS than those who did not receive chemotherapy (P=0.043). Radiation did not significantly influence RFS or OS.Five-year OS was higher than anticipated. Margins >5 mm appear important for local control. Patients with SAS, but not PAS, may achieve improved survival with chemotherapy. National trials using prespecified agents may be needed to identify an optimal chemotherapy regimen for women with SAS.

    View details for DOI 10.1097/COC.0000000000000753

    View details for PubMedID 32889893

  • Reply: Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Kwong, J. W., Azad, A. D., Kahn, D. n., Lee, G. K., Nazerali, R. S. 2020; 145 (2): 451e–452e

    View details for DOI 10.1097/PRS.0000000000006437

    View details for PubMedID 31985679

  • Ultrasound guided liposuction for superficialization of difficult to access arteriovenous fistulas. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Nguyen, A. n., Patel, A. A., Chandra, V. n., Nazerali, R. S. 2020

    View details for DOI 10.1016/j.bjps.2020.08.035

    View details for PubMedID 32863131

  • The antifibrotic adipose-derived stromal cell: Grafted fat enriched with CD74+ adipose-derived stromal cells reduces chronic radiation-induced skin fibrosis. Stem cells translational medicine Borrelli, M. R., Patel, R. A., Adem, S. n., Diaz Deleon, N. M., Shen, A. H., Sokol, J. n., Yen, S. n., Chang, E. Y., Nazerali, R. n., Nguyen, D. n., Momeni, A. n., Wang, K. C., Longaker, M. T., Wan, D. C. 2020

    Abstract

    Fat grafting can reduce radiation-induced fibrosis. Improved outcomes are found when fat grafts are enriched with adipose-derived stromal cells (ASCs), implicating ASCs as key drivers of soft tissue regeneration. We have identified a subpopulation of ASCs positive for CD74 with enhanced antifibrotic effects. Compared to CD74- and unsorted (US) ASCs, CD74+ ASCs have increased expression of hepatocyte growth factor, fibroblast growth factor 2, and transforming growth factor β3 (TGF-β3) and decreased levels of TGF-β1. Dermal fibroblasts incubated with conditioned media from CD74+ ASCs produced less collagen upon stimulation, compared to fibroblasts incubated with media from CD74- or US ASCs. Upon transplantation, fat grafts enriched with CD74+ ASCs reduced the stiffness, dermal thickness, and collagen content of overlying skin, and decreased the relative proportions of more fibrotic dermal fibroblasts. Improvements in several extracellular matrix components were also appreciated on immunofluorescent staining. Together these findings indicate CD74+ ASCs have antifibrotic qualities and may play an important role in future strategies to address fibrotic remodeling following radiation-induced fibrosis.

    View details for DOI 10.1002/sctm.19-0317

    View details for PubMedID 32563212

  • Where Do We Look? Assessing Gaze Patterns in Cosmetic Facelift Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Kwong, J. W., Azad, A. D., Kahn, D. n., Lee, G. K., Nazerali, R. S. 2020

    View details for DOI 10.1097/PRS.0000000000007375

    View details for PubMedID 32947525

  • Commentary on: The Impact of Mastectomy on Women's Visual Perception of Breast Aesthetics and Symmetry: A Pilot Eye-Tracking Study. Aesthetic surgery journal Cai, L., Nazerali, R., Lee, G. K. 2019

    View details for DOI 10.1093/asj/sjz332

    View details for PubMedID 31886480

  • Response to Letter to the Editor: Where Do We Look? Assessing Gaze Patterns in Cosmetic Facelift Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Kwong, J. W., Azad, A. D., Kahn, D., Lee, G. K., Nazerali, R. S. 2019

    View details for DOI 10.1097/PRS.0000000000006437

    View details for PubMedID 31834272

  • Predicting Public Interest in Nonsurgical Cosmetic Procedures Using Google Trends. Aesthetic surgery journal Tijerina, J. D., Morrison, S. D., Nolan, I. T., Parham, M. J., Nazerali, R. 2019

    Abstract

    BACKGROUND: Google Trends (GT) provides cost-free, customizable analyses of search traffic for specified terms entered into Google's search engine. GT may inform plastic surgery marketing decisions and resource allocation.OBJECTIVES: To determine GT's utility in tracking and predicting public interest in nonsurgical cosmetic procedures and to examine trends over time of public interest in nonsurgical procedures.METHODS: GT search volume for terms in 6 ASPS and ASAPS nonsurgical procedure categories (Botox injections, chemical peel, laser hair removal, laser skin resurfacing, microdermabrasion and soft tissue fillers (subcategories: collagen, fat and hyaluronic acid) were compared to ASPS and ASAPS case volumes for the available dates between January 2004 and March 2019 using univariate linear regression with p<0.01 as cutoff for significance.RESULTS: Total search volume varied by search term within the US and internationally. Significant positive correlations were demonstrated for 17 GT terms in all six ASPS and ASAPS categories: "Botox", "collagen injections", "collagen lip injections" with both databases; "chemical skin peel", "skin peel", "acne scar treatment", "CO2 laser treatment", "dermabrasion", "collagen injections", "collagen lip injections", "fat transfer", "hyaluronic acid fillers", "hyaluronic acid injection", "hyaluronic acid injections", "Juvederm", and "fat transfer" with just one database. Many search terms were not significant, emphasizing the need for careful selection of search terms.CONCLUSIONS: Our analysis further elaborates on recent characterization of GT as a powerful and intuitive data set for plastic surgeons, with the potential to accurately gauge global and national interest in topics and procedures related to nonsurgical cosmetic procedures.

    View details for DOI 10.1093/asj/sjz264

    View details for PubMedID 31574152

  • CD146(+) Adipose-Derived Stromal Cells Have Proangiogenic Qualities and Enhance the Regenerative Potential of Grafted Fat Borrelli, M. R., Patel, R. A., Blackshear, C., Vistnes, S., Deleon, N., Nazerali, R., Momeni, A., Dung Nguyen, Longaker, M. T., Wan, D. C. ELSEVIER SCIENCE INC. 2019: S284
  • Google Trends as a Tool for Evaluating Public Interest in Facial Cosmetic Procedures AESTHETIC SURGERY JOURNAL Tijerina, J. D., Morrison, S. D., Nolan, I. T., Vail, D. G., Nazerali, R., Lee, G. K. 2019; 39 (8): 908–18

    View details for DOI 10.1093/asj/sjy267

    View details for Web of Science ID 000475855200028

  • The Power of Patient Norms: Postoperative Pathway Associated With Shorter Hospital Stay After Free Autologous Breast Reconstruction. Annals of plastic surgery Rochlin, D. H., Leon, D. S., Yu, C., Long, C., Nazerali, R., Lee, G. K. 2019; 82 (5S Suppl 4): S320–S324

    Abstract

    INTRODUCTION: Enhanced recovery after surgery pathways designed to optimize postoperative care have become increasingly popular across multiple surgical specialties with proven benefits. In this retrospective cohort study, we present a comparative evaluation of the impact of protocol-based postoperative care on free autologous breast reconstruction patients.METHODS: With institutional review board approval, we performed a chart review of patients who underwent breast reconstruction with free autologous tissue transfer by a single surgeon from 2006 to 2017. Patients were managed according to a postoperative protocol since 2006 that initially called for discharge home on postoperative day (POD) 4 for unilateral cases and POD 5 for bilateral cases. In May 2015, the protocol was revised to discharge home on POD 3 for all cases. Patients who underwent reconstruction before (2006 to April 2015) and after (May 2015 to 2017) the change in postoperative protocol were compared.RESULTS: A total of 432 patients (647 breasts) underwent free autologous breast reconstruction during the study period. Flaps were predominantly muscle-sparing transverse rectus abdominis myocutaneous (56.3%) or deep inferior epigastric perforator (30.3%) flaps. Average patient age was 51.6 years (range, 29.7-80.3 years). Unilateral reconstructions were performed for 167 patients before and 50 patients after the protocol change; average hospital length of stay (LOS) was 4.5 and 3.4 days, respectively (P < 0.001). Bilateral reconstructions were performed for 153 patients before and 62 patients after the protocol change; average hospital LOS was 5.1 and 3.5 days, respectively (P < 0.001). There was no significant increase in patients with major or minor complications.CONCLUSIONS: Revising our postoperative protocol to reduce expected LOS was associated with an overall faster time to discharge without negative consequences in patients who underwent unilateral and bilateral free autologous breast reconstruction. Use of protocols to guide behavior not only can improve the patient experience by promoting a quicker return home, but may also have the added benefit of decreasing healthcare expenditures through reduced inpatient utilization.

    View details for PubMedID 30973838

  • Eighth Dedicated California Society of Plastic Surgeons Annals ANNALS OF PLASTIC SURGERY Nazerali, R., Wong, M. S. 2019; 82: S271

    View details for DOI 10.1097/SAP.0000000000001940

    View details for Web of Science ID 000473280700001

    View details for PubMedID 30950878

  • The Utility of Google Trends Data for Analyzing Public Interest in Breast Procedures ANNALS OF PLASTIC SURGERY Tijerina, J. D., Morrison, S. D., Vail, D. G., Lee, G. K., Nazerali, R. 2019; 82: S325–S331
  • The Power of Patient Norms Postoperative Pathway Associated With Shorter Hospital Stay After Free Autologous Breast Reconstruction Rochlin, D. H., Leon, D., Yu, C., Long, C., Nazerali, R., Lee, G. K. LIPPINCOTT WILLIAMS & WILKINS. 2019: S320–S324
  • Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology ANNALS OF PLASTIC SURGERY Kwong, J. W., Cai, L. Z., Azad, A. D., Lorenz, H., Khosla, R. K., Lee, G. K., Nazerali, R. S. 2019; 82: S313–S319
  • Health-Related Quality of Life After Ventral Hernia Repair With Biologic and Synthetic Mesh Nissen, A. T., Henn, D., Moshrefi, S., Gupta, D., Nazerali, R., Lee, G. K. LIPPINCOTT WILLIAMS & WILKINS. 2019: S332–S338

    Abstract

    Quality of life (QOL) is an important outcome measure after ventral hernia repair (VHR). The Hernia-Related QOL Survey (HerQLes) is a specific survey tool for QOL after VHR. Studies comparing QOL in patients with biologic mesh repairs (BMRs) and synthetic mesh repairs (SMRs) are lacking.A survey based on the HerQLes was administered via e-mail to 974 patients who had undergone VHR at Stanford Medical Center. From 175 patients who were included in the study, the mean HerQLes scores and postoperative complications were compared between patients with suture repairs (SR), BMR, SMR, with and without component separation, and different types of SMR.Quality of life was lower in patients with hernias of 50 cm or greater, obesity, history of tobacco use, previous abdominal surgeries, hernia recurrences, and postoperative complications (P < 0.05). Patients with SR and SMR had a comparable QOL (71.58 vs 70.12, P = 0.75). In patients with Modified Ventral Hernia Working Group grade 2 hernias, a significantly lower QOL was found after BMR compared with SMR. Postoperative complications did not significantly differ between the groups. Recurrence rates were comparable between MR (10.4%) and SR (8.3%, P = 0.79), but higher in BMR (21.7%) compared with SMR (6.6%, P < 0.05).Previous abdominal surgeries, previous hernia repairs, tobacco use, and hernia sizes of 50 cm or greater negatively affect QOL after VHR. Our data indicate that QOL is comparable between patients with SMR and SR, however, is lower in patients with Modified Ventral Hernia Working Group grade 2 and BMR compared with SMR, raising the benefit of BMR in light of its higher cost into question.

    View details for DOI 10.1097/SAP.0000000000001768

    View details for Web of Science ID 000473280700012

    View details for PubMedID 30633027

  • Where Do We Look? Assessing Gaze Patterns in Cosmetic Facelift Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Kwong, J. W., Azad, A. D., Kahn, D., Lee, G. K., Nazerali, R. S. 2019

    Abstract

    PURPOSE: Aesthetics plays a central role in determining success in plastic surgery. Understanding perceptions of favorable aesthetics is critical to ensure patient satisfaction. Eye-tracking technology offers an objective way to evaluate attention and understand how viewers direct their focus in patients who undergo cosmetic facelift procedures.METHODS: Thirty-six subjects ranging from layperson to attending plastic surgeon viewed 15 sets of photos before and after patients underwent an elective facelift procedure. They were instructed to evaluate the aesthetic quality on a Likert scale, while eye-tracking equipment tracked their gaze and analyzed their distribution of attention.RESULTS: Post-operative images showed a Likert score improvement of 0.51±0.26, with the greatest difference in attending cosmetic plastic surgeons (1.36±0.22; p<0.05). The nose was the most common first fixation location (31% of first fixations) and the most viewed area (16±3% of fixation time) for all subjects. Experienced subjects spent less time in non-relevant areas (30±11% for attending cosmetic plastic surgeons and 37±10% for attending non-cosmetic plastic surgeons) compared to less experienced subjects (50±15% for laypersons).CONCLUSIONS: This study demonstrates that viewers with greater experience in cosmetic surgery focus quickly on the cheeks, chin, and neck and have evenly distributed gaze across the entire face. These results suggest that laypersons' gaze are drawn to the center of the face - due to both unfamiliarity with the facelift procedure and the natural tendency to look at the central face - while attending plastic surgeons exhibit holistic gaze patterns and are more aware of the impact of the procedure.

    View details for PubMedID 30998662

  • Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology. Annals of plastic surgery Kwong, J. W., Cai, L. Z., Azad, A. D., Lorenz, H. P., Khosla, R. K., Lee, G. K., Nazerali, R. S. 2019

    Abstract

    BACKGROUND: Cleft lip repair is essential to restoring physiologic function and ensuring social and psychological well-being in children with orofacial clefts. It is important to critically study various techniques to understand the elements of the lip and nasal repair that contribute to favorable results. Here, we use eye-tracking technology to evaluate how viewers analyze images of cleft lips repaired by the Fisher, Millard, or Mohler techniques.METHODS: Thirty viewers were shown 5 images without deformity and 5 images each of unilateral cleft lips repaired by the Fisher, Millard, or Mohler techniques. Viewers assessed the esthetic quality of images on a Likert scale while eye-tracking technology analyzed their gaze patterns.RESULTS: Of the 3 repair techniques, viewers found Fisher repairs most esthetically pleasing (mean ± standard error, 6.91 ± 0.13). Mohler repairs were next most attractive at (6.47 ± 0.13), followed by Millard repairs at (5.60 ± 0.14). The proportion of time spent in fixed gaze on the nose and upper lip was greatest for Millard repairs (58.3% ± 0.4%) and least for Fisher repairs (51.9% ± 0.5%). Viewers fixated most frequently on the nose and upper lip in Millard repairs (83.2% ± 0.5%) and least frequently in Fisher repairs (75.3% ± 0.5%). When examining the Millard compared with Fisher and Mohler repairs, viewers spent more time and fixations on the ipsilateral lip, nose, and repair scar than on the contralateral lip.CONCLUSIONS: The esthetics of the Fisher repair appear to be favored as measured by Likert scores and gaze data. Eye-tracking technology may be a useful tool to assess outcomes in plastic surgery.

    View details for PubMedID 30882421

  • The Utility of Google Trends Data for Analyzing Public Interest in Breast Procedures. Annals of plastic surgery Tijerina, J. D., Morrison, S. D., Vail, D. G., Lee, G. K., Nazerali, R. 2019

    Abstract

    BACKGROUND: Google Trends (GT) is a free, open-source tool that permits customizable analysis of search term volumes entered into the Google search engine. Google Trends data may offer useful and actionable insight to plastic surgeons pertaining to worldwide, national, and regional evolution of patient interest for breast procedures and other common surgeries.METHODS: Search terms were generated using the "related queries" feature of GT. Google Trends data were collected for breast lift, breast reduction, breast reconstruction, and male breast reduction from January 2004 to September 2017. Case volumes for respective procedures were obtained from the American Society of Plastic Surgeons (ASPS) annual statistics reports for the calendar year 2006 to 2016. Trend analysis was performed using univariate linear regression analysis of ASPS statistics and GT search data.RESULTS: Total search volume varied geographically and temporally during the study period. Statistically significant positive correlations between GT and ASPS data were as follows: breast lift: "mastopexy" (R = 0.445, P = 0.025); male breast reduction: "gynecomastia surgery" (R = 0.45, P = 0.024); and breast reconstruction: "tissue expander" (R = 0.806, P ≤ 0.001) and "TRAM flap reconstruction" (R = 0.764, P = 0.002). For several search terms, no significant correlation was detected, highlighting the importance for careful selection of terms.

    View details for PubMedID 30870175

  • The quality of systematic reviews addressing peripheral nerve repair and reconstruction JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sun, B. J., Tijerina, J. D., Agbim, U. N., Lee, G. K., Nazerali, R. S. 2019; 72 (3): 447–56
  • Analysis and Interpretation of Google Trends Data on Public Interest in Cosmetic Body Procedures. Aesthetic surgery journal Tijerina, J. D., Morrison, S. D., Nolan, I. T., Vail, D. G., Lee, G. K., Nazerali, R. 2019

    Abstract

    BACKGROUND: Several online resources such as Google Trends (GT) enable plastic surgeons to track search volume trends for cosmetic procedures. Understanding these data may allow surgeons to better anticipate patients' interests and meet their needs.OBJECTIVES: Evaluate the correlation between GT search volumes and annual surgery volumes.METHODS: Search terms were generated using the "related queries" feature of GT. Data were obtained for the terms breast augmentation, buttock augmentation, buttock implants, buttock lift, calf augmentation, liposuction, lower body lift, thighplasty, abdominoplasty, and brachioplasty from January 2004 to November 2017. Annual volumes for respective procedures were obtained from statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. Correlations were evaluated using univariate linear regression of GT data to both ASPS and ASAPS data.RESULTS: Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: were: "butt implants surgery" (ASPS R2=0.366, p=0.049; ASAPS R2=0.380, p=0.019); "liposuction" (ASPS R2=0.690, p=0.002; ASAPS R2=0.578, p=0.002); and "liposuction surgery" (ASPS R2=0.672, p=0.002; ASAPS R2=0.476, p=0.006). Several search terms demonstrated no significant relationships, negative correlations, or were significant with only one database.CONCLUSIONS: Our study characterizes GT as a convenient and informative data set for plastic surgeons to analyze patient interest in cosmetic body-sculpting procedures. GT represents a useful instrument for tailoring marketing strategies and addressing the needs of our patient population.

    View details for PubMedID 30810161

  • Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Kwong, J. W., Azad, A. D., Kahn, D. n., Lee, G. K., Nazerali, R. S. 2019; 144 (1): 63–70

    Abstract

    Aesthetics plays a central role in determining success in plastic surgery. Understanding perceptions of favorable aesthetics is critical to ensure patient satisfaction. Eye-tracking technology offers an objective way of evaluating attention and understanding how viewers direct their focus on patients who undergo cosmetic face-lift procedures.Thirty-six subjects ranging from layperson to attending plastic surgeon viewed 15 sets of photographs before and after patients underwent an elective face-lift procedure. They were instructed to evaluate the aesthetic quality on a Likert scale while eye-tracking equipment tracked their gaze and analyzed their distribution of attention.Postoperative images showed a Likert score improvement of 0.51 ± 0.26, with the greatest difference in attending cosmetic plastic surgeons (1.36 ± 0.22; p < 0.05). The nose was the most common first fixation location (31 percent of first fixations) and the most viewed area (16 ± 3 percent of fixation time) for all subjects. Experienced subjects spent less time in nonrelevant areas (30 ± 11 percent for attending cosmetic plastic surgeons and 37 ± 10 percent for attending noncosmetic plastic surgeons) compared with less experienced subjects (50 ± 15 percent for laypersons).This study demonstrates that viewers with greater experience in cosmetic surgery focus quickly on the cheeks, chin, and neck and have evenly distributed gaze across the entire face. These results suggest that a layperson's gaze is drawn to the center of the face (because of both unfamiliarity with the face-lift procedure and the natural tendency to look at the central face), whereas attending plastic surgeons exhibit holistic gaze patterns and are more aware of the impact of the procedure.

    View details for DOI 10.1097/PRS.0000000000005700

    View details for PubMedID 31246802

  • Celebrity Influence Affecting Public Interest in Plastic Surgery Procedures: Google Trends Analysis. Aesthetic plastic surgery Tijerina, J. D., Morrison, S. D., Nolan, I. T., Parham, M. J., Richardson, M. T., Nazerali, R. n. 2019

    Abstract

    Medical decisions made by celebrities have a profound influence on medical decisions made by the general population. Google Trends (GT) is a free, online resource with virtually no barriers to use that allows for tracking of global search volumes as a proxy for determining public interest. In this study, we utilize GT to characterize the significant and measurable effects that the May 2013 announcement of Angelina Jolie's BRCA-influenced prophylactic mastectomy, May 2015 announcement of Kylie Jenner's lip augmentation, April 2017 announcement of Caitlyn Jenner's gender affirming surgery and February 2014 media attention given to Kim Kardashian's rumored buttock augmentation had on corresponding surgical procedure volumes.GT databases of search volumes were collected for terms related to prophylactic mastectomy, lip augmentation, gender affirming surgery and buttock augmentation categories from January 2004 to March 2019 using the "related queries" feature. Mean search volumes prior to respective announcements were compared to that of the period starting 6 months after. Additionally, the percent change from the month preceding respective celebrity announcements was compared to the month of the announcement for each search term.For mastectomy, all terms demonstrated peak interest during May 2013. Following Jolie's announcement, interest in "mastectomy" rose 1328%, "prophylactic mastectomy" rose 324%, "BRCA1" rose 316%, "BRCA2" rose 138% and "BRCA gene" rose 354%. Long-term interest was higher after May 2013 than beforehand for all terms except "prophylactic mastectomy" (each, p < 0.001). Following Kylie Jenner's announcement, interest in "lip augmentation" rose 43%, "lip enhancement" rose 37%, "lip fillers" rose 3233%, "lip implants" rose 8% and "lip injections" rose 13%. Long-term interest was higher after May 2015 than beforehand for all terms except "lip augmentation" and "lip enhancement" (each, p < 0.001). Following Caitlyn Jenner's announcement, "gender affirming surgery" rose 119%, "gender reassignment" rose 186%, "gender reassignment surgery" rose 203% and "transgender surgery" rose 35%. Long-term interest was higher after April 2017 than beforehand for all terms except "sex change" (each, p < 0.001). Following Kardashian's rumored injections, interest in "butt enhancement" rose 34% and "butt implants" rose 100%. Long-term interest was higher after February 2014 than beforehand for all terms (each, p < 0.001).GT data trends correlate with shifts in real-world healthcare utilization and healthcare-related public interest caused by high-profile public events, making it a useful tool for real-time prediction of trends in public health in response to a variety of observable influences.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

    View details for DOI 10.1007/s00266-019-01466-7

    View details for PubMedID 31392394

  • The quality of systematic reviews addressing peripheral nerve repair and reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Sun, B. J., Tijerina, J. D., Agbim, U. N., Lee, G. K., Nazerali, R. S. 2018

    Abstract

    While systematic reviews are regarded as the strongest level of medical evidence, inconsistency in the quality and rigor of systematic reviews raises concerns about their use as a tool in guiding quality delivery in evidence-based clinical practice. The objective of this present study was to assess methodological soundness of systematic reviews with a particular focus on peripheral nerve repair and reconstruction. We performed a comprehensive search using PubMed and Scopus to identify all systematic reviews published on peripheral nerve reconstruction in 9 high-impact surgical journals. Two authors independently performed literature searches, screened abstracts, and extracted data. Discrepancies were resolved by discussion and consensus. The quality of systematic reviews was assessed using AMSTAR criteria. Initial search retrieved 184 articles. After screening duplicates, titles, abstracts, and conducting full text reviews, 26 studies met inclusion criteria. Of those, 18 (65%) were published by Plastic Surgery, 7 (27%) by Orthopedic Surgery, and 1 (4%) by Occupational Therapy. The total number of systematic reviews published on peripheral nerves each year has shown an increasing trend from 2004 through 2015. The overall median AMSTAR score was 5, reflecting a "fair" quality. There was no evidence of AMSTAR score improvement over time. Although the number of systematic reviews published on peripheral nerve repair has risen over the last decade, their quality has not exhibited the same increase. This highlights the necessity to increase familiarity with and conform to methodological quality criteria in order to improve the integrity of evidence-based medicine in peripheral nerve repair and reconstruction.

    View details for PubMedID 30655242

  • Reply: Where Do We Look? Assessing Gaze Patterns in Breast Reconstructive Surgery with Eye-Tracking Technology PLASTIC AND RECONSTRUCTIVE SURGERY Cai, L. Z., Paro, J. M., Lee, G. K., Nazerali, R. S. 2018; 142 (5): 792E–793E
  • Google Trends as a Tool for Evaluating Public Interest in Facial Cosmetic Procedures. Aesthetic surgery journal Tijerina, J. D., Morrison, S. D., Nolan, I. T., Vail, D. G., Nazerali, R., Lee, G. K. 2018

    Abstract

    Background: The utility of Google Trends (GT) in analyzing worldwide and regional patient interest for plastic surgery procedures is becoming invaluable to plastic surgery practices. GT data may offer practical information to plastic surgeons pertaining to seasonal and geographic trends in interest in facial cosmetic procedures.Objective: The authors sought to analyze geographic and temporal trends between GT search volumes and US surgery volumes using univariate analysis.Methods: The "related queries" feature of GT generated potential search terms. GT data were compiled for cheek implants, mentoplasty, otoplasty, blepharoplasty, rhytidectomy, forehead lift, hair transplantation, lip augmentation, lip reduction, platysmaplasty, and rhinoplasty from January 2004 to December 2017. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017.Results: Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: "eyelid plastic surgery" (ASPS R2=0.336, P=0.048; ASAPS R2=0.661, P=0.001); "facelift" (ASPS R2=0.767, P≤0.001; ASAPS R2=0.767, P=0.001); "lip injections" (ASPS R2=0.539, P=0.007; ASAPS R2=0.461, P=0.044); and "rhinoplasty surgery" (ASPS R2=0.797, P≤0.001; ASAPS R2=0.441, P=0.01). Several search terms demonstrated no significant relationships or were significant with only one database.Conclusions: GT may provide a high utility for informing plastic surgeons about the interest expressed by our patient population regarding certain cosmetic search terms and procedures. GT may represent a convenient tool for optimizing marketing and advertising decisions.

    View details for PubMedID 30304356

  • Utilizing Confocal Microscopy to Characterize Human and Mouse Adipose Tissue TISSUE ENGINEERING PART C-METHODS Blackshear, C. P., Borrelli, M. R., Shen, E. Z., Ransom, R., Chung, N. N., Vistnes, S. M., Irizarry, D., Nazerali, R., Momeni, A., Longaker, M. T., Wan, D. C. 2018; 24 (10): 566–77
  • Utilizing Confocal Microscopy to Characterize Human and Mouse Adipose Tissue. Tissue engineering. Part C, Methods Blackshear, C., Borrelli, M. R., Shen, E. Z., Ransom, R. C., Chung, N. N., Vistnes, S., Irizarry, D., Nazerali, R., Momeni, A., Longaker, M. T., Wan, D. C. 2018

    Abstract

    Significant advances in our understanding of human obesity, endocrinology, and metabolism have been made possible by murine comparative models, in which anatomically analogous fat depots are utilized; however, current research has questioned how truly analogous these depots are. In this study, we assess the validity of the analogy from the perspective of cellular architecture. Whole tissue mounting, confocal microscopy, and image reconstruction software were employed to characterize the three-dimensional structure of the inguinal fat pad in mice, gluteofemoral fat in humans, and subcutaneous adipose tissue of the human abdominal wall. Abdominal and gluteofemoral adipose tissue specimens from 12 human patients and bilateral inguinal fat pads from 12 mice were stained for adipocytes, blood vessels, and a putative marker for adipose-derived multipotent progenitor cells, CD34. Samples were whole-mounted and imaged with laser scanning confocal microscopy. Expectedly, human adipocytes were larger and demonstrated greater size heterogeneity. Mouse fat displayed significantly higher vascular density compared to human fat when normalized to adipocyte count. There was no significant difference in the concentration of CD34+ stromal cells from either species. However, the mean distance between CD34+ stromal cells and blood vessels was significantly greater in human fat. Finally, mouse inguinal fat contained larger numbers of brown adipocytes than did human gluteofemoral or human abdominal fat. Overall, the basic architecture of human adipose tissue differs significantly from that of mice. Insofar as human gluteofemoral fat differs from human abdominal adipose tissue, it was closer to mouse inguinal fat, being its comparative developmental analogue. These differences likely confer variance in functional properties between the two sources, and thus must be considered when designing murine models of human disease.

    View details for PubMedID 30215305

  • Response: Where Do We Look? Assessing Gaze Patterns in Reconstructive Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Paro, J. A., Lee, G. K., Nazerali, R. S. 2018

    View details for PubMedID 30222674

  • Using Mesh to Reinforce the Abdominal Wall in Abdominal Free Flaps for Breast Reconstruction: Is There a Benefit? What are the Risks? Annals of plastic surgery Leon, D. S., Nazerali, R., Lee, G. K. 2018; 80 (5S Suppl 5): S295–S298

    Abstract

    INTRODUCTION: Abdominal wall integrity may be compromised after abdominal flap harvest for breast reconstruction, leading to bulging or herniation due to weakening of the abdominal wall and dissection through the rectus muscle. Mesh can be used to reinforce the abdominal wall to reduce the risk of hernia formation postoperatively, especially in patients who may be at high risk. In this study, we describe this institution's experience with the use of mesh in the abdominal wall and critically evaluate its impact on patient outcomes and complications.METHODS: We retrospectively reviewed all patients with an abdominal free flap harvested for breast reconstruction at Stanford Health Care from 2005 to 2015. Multivariate-adjusted logistic regression analysis was used to compare the odds of abdominal complications-infection, bulging, and herniation-between patients with and without an abdominal mesh implanted during breast reconstruction.RESULTS: Three hundred eighty patients met inclusion criteria. One hundred sixty-one patients received mesh, whereas 219 received no reinforcement. In the mesh group, there were 7 (4.3%) cases of postoperative abdominal bulging, 11 (6.8%) cases of abdominal infection, and no (0.0%) cases of herniation. In the group without mesh, there were 17 (7.8%) cases of abdominal bulging, 11 (5.0%) cases of abdominal infection, and 5 (2.3%) cases of herniation. There was a significant difference in the odds of bulging (odds ratio [OR], 0.30; P = 0.01). There was not a significant difference in the odds of herniation (OR, 2.26E-10; P = 0.99) or infection (OR, 1.21; P = 0.69).CONCLUSIONS: In our current treatment algorithm, patients who received mesh were selected based upon several criteria, including obesity, weak fascia identified during surgery, and extensive muscle dissection. We confirm that the risk of bulging and herniation is decreased in patients receiving mesh. Furthermore, the risk of wound infection was not associated with the use of mesh; instead, a patient's elevated body mass index, as well as tension of closure, and other comorbidities are more likely causes of superficial wound complications. We find the use of mesh to be safe and beneficial in select patients undergoing abdominal free flap breast reconstruction who are at risk for hernias and bulges.

    View details for PubMedID 29596090

  • The Quality of Systematic Reviews in Head and Neck Microsurgery A Perspective from Plastic Surgery and Otolaryngology Sun, B. J., Tijerina, J., Nazerali, R. S., Lee, G. K. LIPPINCOTT WILLIAMS & WILKINS. 2018: S267–S273

    Abstract

    In recent years, there has been a push to publish higher level of evidence studies in medicine, particularly in plastic surgery. Well-conducted systematic reviews are considered the strongest level of evidence in medicine, recently becoming the key process indicators for quality delivery. A varying quality of systematic reviews, however, has led to concerns of their validity in clinical decision-making. We perform a quality analysis of systematic reviews published in head and neck microsurgery by the surgical specialties of plastic surgery and otolaryngology.An evaluation of systematic reviews published on microsurgery in 13 high-impact surgical journals was conducted by searching PubMed and Scopus. Two authors independently performed searches, screened for eligibility, and extracted data from included articles. Discrepancies were resolved by discussion and consensus. Assessment of Multiple Systematic Reviews (AMSTAR) criteria were used to assess methodological quality.The initial database search retrieved 166 articles. After removing duplicates, screening titles and abstracts, 26 articles remained for full text review. Seven did not focus on head and neck microsurgery and were further excluded, leaving 19 systematic reviews for final analysis. Of those, 10 systematic reviews were published by otolaryngology, and 9 were published by plastic surgery. Median AMSTAR score was 8 for otolaryngology, 7 for plastic surgery, and 8 overall, reflecting "fair to good" quality. The number of systematic reviews on head and neck microsurgery markedly increased over time. Of note, both the AMSTAR score and the number of systematic reviews published by plastic surgery have steadily increased from 2014 to 2016, whereas those published by otolaryngology have remained relatively stable since 2010.Our review shows a trend toward publishing more systematic reviews. The increasing quantity and quality of systematic reviews published by plastic surgeons indicates recognition in the need for higher levels of evidence in plastic surgery, as well as growing interest and advances in microsurgery. Given these trends, familiarity with quality assessment guidelines, such as AMSTAR, will remain important in providing a basis for building relevant value-based quality measures.

    View details for DOI 10.1097/SAP.0000000000001384

    View details for Web of Science ID 000473114300008

    View details for PubMedID 29489536

  • Seventh Dedicated California Society of Plastic Surgeons Annals ANNALS OF PLASTIC SURGERY Nazerali, R., Wong, M. S. 2018; 80: S239–S240

    View details for DOI 10.1097/SAP.0000000000001467

    View details for Web of Science ID 000473114300001

    View details for PubMedID 29620553

  • Where Do We Look? Assessing Gaze Patterns in Breast Reconstructive Surgery with Eye-Tracking Technology PLASTIC AND RECONSTRUCTIVE SURGERY Cai, L. Z., Paro, J. M., Lee, G. K., Nazerali, R. S. 2018; 141 (3): 331E–340E

    Abstract

    Aesthetics plays a large role in determining a successful outcome in plastic and reconstructive surgery. As such, understanding perceptions of favorable aesthetics is crucial for optimizing patient satisfaction. Eye-tracking technology offers an unbiased way of measuring how viewers evaluate breast reconstructions.Twenty-nine raters with varied plastic surgery experience were shown 20 images of breast reconstruction at various stages. Breasts were divided into those with nipples and no reconstruction scars, those with nipples and reconstruction scars, and those with reconstruction scars and no nipples. Raters viewed each image for 8 seconds to evaluate aesthetic outcomes. Eye-tracking equipment and software were used to track raters' gaze and analyze the distribution of attention.In breasts with reconstruction scars and no nipples, viewers spent 53.9 percent of the view time examining scars, whereas viewers' attention was divided evenly in breasts with both reconstruction scars and nipples, spending 27.5 percent and 27.7 percent of view time examining the nipples and reconstruction scars, respectively. When examining complete reconstructions, viewers spent more time scanning the entire image before fixating on scars and spent less time on single-site fixation.Complete reconstructions, which notably include the final nipple-areola complex, appear to play an important role in restoring normal viewing parameters. In essence, completed breast reconstructions with nipple-areola complexes divert attention from extraneous surgical scars and lead viewers to assess the breasts more holistically. Eye-tracking technology provides a powerful link between objective gaze and viewer attention that may potentially be used to predict subjective aesthetic preferences.

    View details for PubMedID 29481389

  • Delayed prosthetic breast reconstruction without the use of acellular dermal matrix EUROPEAN JOURNAL OF PLASTIC SURGERY Mittermiller, P. A., Nazerali, R. S., Glaus, S. W., Perez, M. G., Luan, A., Kahn, D. M., Lee, G. K. 2017; 40 (6): 533–40
  • Massive localized lymphedema of the mons: the pi-cut technique EUROPEAN JOURNAL OF PLASTIC SURGERY Shih, H. B., Nazerali, R., Gurjala, A., Jazayeri, L., Lee, G. K. 2017; 40 (4): 343–46
  • Quality Measures in Breast Reconstruction: A Systematic Review. Annals of plastic surgery Nazerali, R. N., Finnegan, M. A., Divi, V., Lee, G. K., Kamal, R. N. 2017

    Abstract

    The importance of providing quality care over quantity of care, and its positive effects on health care expenditure and health, has motivated a transition toward value-based payments. The Centers for Medicare and Medicaid Services and private payers are establishing programs linking financial incentives and penalties to adherence to quality measures. As payment models based on quality measures are transitioned into practice, it is beneficial to identify current quality measures that address breast reconstruction surgery as well as understand gaps to inform future quality measure development.We performed a systematic review of quality measures for breast reconstruction surgery by searching quality measure databases, professional society clinical practice guidelines, and the literature. Measures were categorized as structure, process, or outcome according to the Donabedian domains of quality.We identified a total of 27 measures applicable to breast reconstruction: 5 candidate quality measures specifically for breast reconstruction surgery and 22 quality measures that relate broadly to surgery. Of the breast reconstruction candidate measures, 3 addressed processes and 2 addressed outcomes. Seventeen of the general quality measures were process measures and 5 were outcome measures. We did not identify any structural measures.Currently, an overrepresentation of process measures exists, which addresses breast reconstruction surgery. There is a limited number of candidate measures that specifically address breast reconstruction. Quality measure development efforts on underrepresented domains, such as structure and outcome, and stewarding the measure development process for candidate quality measures can ensure breast reconstruction surgery is appropriately evaluated in value-based payment models.

    View details for DOI 10.1097/SAP.0000000000001088

    View details for PubMedID 28570449

  • Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sheckter, C. C., Shakir, A., Vo, H., Tsai, J., Nazerali, R., Lee, G. K. 2016; 69 (11): 1506-1512

    Abstract

    Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred.A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications.A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p = 0.039).Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.

    View details for DOI 10.1016/j.bjps.2016.06.024

    View details for Web of Science ID 000388293400012

    View details for PubMedID 27538340

  • Superior Gluteal Artery Perforator Flap: The Beauty of the Buttock. Annals of plastic surgery Hunter, C., Moody, L., Luan, A., Nazerali, R., Lee, G. K. 2016; 76: S191-5

    Abstract

    The superior gluteal artery perforator (SGAP) flap is a useful technique for breast reconstruction. This perforator flap allows for the transfer of the patient's own skin and subcutaneous tissue with minimal donor-site morbidity. Despite its usefulness, the SGAP flap is not widely used among reconstructive surgeons. The challenging perforator dissection and need for microsurgery may contribute to the reluctant use of the flap by many reconstructive surgeons. The ability to perform a single-stage breast reconstruction with buttock tissue when abdominal or thigh tissue are unavailable provides a significant service to the patient desiring an autologous breast reconstruction.The authors performed a retrospective review and outcomes analysis of a single surgeon's surgical technique and experience. Consecutive patients, who underwent SGAP flaps for breast reconstruction during a 7-year period from 2007 to 2014, were compared to a matched cohort of consecutive patients undergoing deep inferior epigastric perforator (DIEP) flaps and clinical outcomes were analyzed.Thirteen patients underwent SGAP flap breast reconstruction for a total of 16 flaps during the study period compared to 34 consecutive DIEP flaps for breast reconstruction. There was no significant difference in flap or donor-site complications between the 2 groups. There was no statistically significant difference between the average operative time for unilateral breast reconstruction in the SGAP and DIEP flap groups. In 4 patients, a bipedicled SGAP flap was used due to perforator anatomy. All SGAP patients returned to full activity. Average follow-up time was 1 year.Although utilization of buttock tissue for breast reconstruction can be challenging and requires microsurgical expertise, in the hands of experienced microsurgeons the SGAP flap is a safe and reliable option for autologous breast reconstruction with minimal donor-site morbidity and excellent aesthetic results.

    View details for DOI 10.1097/SAP.0000000000000723

    View details for PubMedID 26808742

  • The Use of the Sternocleidomastoid Flap Helps Reduce Complications After Free Jejunal Flap Reconstructions in Total Laryngectomy and Cervical Esophagectomy Defects. Annals of plastic surgery Moody, L., Hunter, C., Nazerali, R., Lee, G. K. 2016; 76: S209-12

    Abstract

    Esophageal reconstruction after tumor extirpation or ingestion injury is a difficult problem for the reconstructive plastic surgeon. Free tubed fasciocutaneous flaps and intestinal flaps have become the mainstay for reconstruction. The free jejunal flap has the advantage of replacing like-with-like tissue and having lower fistula rates. Additionally, the "mesenteric wrap" modification and prophylactic pectoralis major muscle have been described to further decrease anastomotic leaks and fistulae. The purpose of this study was to describe the use of the prophylactic pedicled sternocleidomastoid (SCM) flap for prevention of anastomotic leaks and fistulae.A retrospective review of patients who underwent reconstruction of circumferential pharyngoesophageal defects with a free jejunal flap by a single surgeon from 2008 to 2012 was performed. Those who received a prophylactic pedicled SCM flap to reinforce one of their jejunal anastomoses were selected for this study, and their outcomes were analyzed. Patients' demographics, comorbidities, complications, and clinical outcomes were collected and analyzed.Three patients underwent reinforcement of one jejunal anastomosis with a pedicled SCM flap. The mean age was 60 years, and average follow-up was 27 months. Two patients received postoperative radiation, and one patient received both preoperative and postoperative radiation. The recipient vessels included the facial artery, internal jugular vein, and facial vein. The flap survival rate was 100%. There was 1 stricture and 1 fistula that occurred at the anastomoses without the SCM muscle reinforcement. There were no complications at the jejunal anastomotic sites that were reinforced with the SCM muscle. Of the 6 anastomotic sites in 3 patients, there was a 0% fistula rate and 0% stricture rate at the sites reinforced with the SCM muscle versus a 33% fistula rate and a 33% stricture rate at the sites without the SCM muscle flap. One patient was diagnosed with local tumor recurrence and eventually succumbed to the progression of their disease. All patients were able to tolerate an oral diet without supplemental feeds. All patients were able to achieve intelligible speech via an electrolarynx or esophageal speech.Reconstruction of pharyngoesophageal defects can be technically challenging and requires extensive planning and careful execution. The free jejunal flap restores alimentary continuity with good functional outcomes. Fistula rates may be decreased with the use of a prophylactic SCM flap to reinforce the jejunal anastomosis.

    View details for DOI 10.1097/SAP.0000000000000724

    View details for PubMedID 26849282

  • World's First Baby Born Through Natural Insemination by Father With Total Phalloplasty Reconstruction ANNALS OF PLASTIC SURGERY Gurjala, A. N., Nazerali, R. S., Salim, A., Lee, G. K. 2016; 76: S179-S183

    Abstract

    Techniques for neophallus reconstruction have become increasingly refined, fulfilling more criteria for what is considered to be the ideal penis reconstruction. For both trauma and transgender populations, the radial forearm free flap remains the gold standard, although the pedicled or free anterolateral thigh flap is becoming a favored alternative. Despite the remarkably high rates of sexual activity reported by patients having benefited from these techniques, sexual function remains a significant challenge due to frequent complications including autologous and prosthetic stiffener failure, fistula formation, and inadequate erogenous sensation. Perhaps the ultimate criterion for neophallus reconstruction is one which not only avoids these complications by meeting the immediate goals of a competent neourethra, sensitivity, bulk, and aesthetic form but also successfully combines them into their true overarching function: procreation. In this article, we report the case of a pedicled anterolateral thigh flap neophallus reconstruction which allowed a patient to naturally conceive a child through penetrative intercourse without use of a stiffener, and led to pregnancy and subsequent birth of a baby son. We review the surgical techniques and factors that led to this patient's successful progeny.

    View details for DOI 10.1097/SAP.0000000000000769

    View details for Web of Science ID 000375061200009

    View details for PubMedID 27070679