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


  • 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
  • '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

  • 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
  • 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
  • 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

  • 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 (2): 451e–452e

    View details for DOI 10.1097/PRS.0000000000006437

    View details for PubMedID 31985679

  • 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

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

    View details for DOI 10.1097/SLA.0000000000003998

    View details for PubMedID 32675504

  • 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

  • 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

  • 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; 146 (6): 821e–822e

    View details for DOI 10.1097/PRS.0000000000007375

    View details for PubMedID 33234991

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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