Marek A. Paul

The Current Role of Three-Dimensional Printing in Plastic Surgery

Summary: Since the advent of three-dimensional printing in the 1980s, it has become possible to produce physical objects from digital files and create three-dimensional objects by adding one layer at a time following a predetermined pattern. Because of the continued development of inexpensive and easy-to-use three-dimensional printers and bioprinting, this technique has gained more momentum over time, especially in the field of medicine. This article reviews the current and possible future application of three-dimensional printing technology within the field of plastic and reconstructive surgery.

Analyzing Regional Differences over a 15-Year Trend of One-Stage versus Two-Stage Breast Reconstruction in 941,191 Postmastectomy Patients.

BACKGROUND Implant-based reconstruction is the predominant form of breast reconstruction, with the two-stage tissue expander/implant approach being the most popular. Recently, the direct-to-implant, one-stage breast reconstruction procedure has gained momentum. In this study, national and regional trends across the United States for the two different types of implant-based reconstructions were evaluated. METHODS The Nationwide Inpatient Sample database was used to extrapolate data on type of mastectomy, implant-based reconstructive technique (one-stage or two-stage), and sociodemographic and hospital variables. Differences were assessed using the chi-square test, impact of variables on reconstructive method was analyzed using logistic regression, and trends were analyzed using the Cochrane-Armitage test. RESULTS Between 1998 and 2012, a total of 1,444,587 patients treated for breast cancer or at increased risk of breast cancer met the defined selection criteria. Of these, 194,377 patients underwent implant-based breast reconstruction (13.6 percent one-stage and 86.4 percent two-stage). In both, there was a significant increase in procedures performed over time (p < 0.001). The highest increase in both was seen in the Northeast region of the United States, and the lowest increase was seen in the South. When stratified into regions, analysis showed differences in socioeconomic and hospital characteristics within the different regions. CONCLUSIONS There is an observed increase in the number of one-stage and two-stage breast reconstructions being performed. Sociodemographic and hospital factors of influence vary in the different regions of the United States. This study provides important information for clinicians and policy makers who seek to ensure equitable and appropriate access for patient to the different types of implant-based procedures.

Plastic Surgery Training Worldwide: Part 1. The United States and Europe

Background: Major differences exist in residency training, and the structure and quality of residency programs differ between different countries and teaching centers. It is of vital importance that a better understanding of the similarities and differences in plastic surgery training be ascertained as a means of initiating constructive discussion and commentary among training programs worldwide. In this study, the authors provide an overview of plastic surgery training in the United States and Europe. Methods: A survey was sent to select surgeons in 10 European countries that were deemed to be regular contributors to the plastic surgery literature. The questions focused on pathway to plastic surgery residency, length of training, required pretraining experience, training scheme, research opportunities, and examinations during and after plastic surgery residency. Results: Plastic surgery residency training programs in the United States differ from the various (selected) countries in Europe and are described in detail. Conclusions: Plastic surgery education is vastly different between the United States and Europe, and even within Europe, training programs remain heterogeneous. Standardization of curricula across the different countries would improve the interaction of different centers and facilitate the exchange of vital information for quality control and future improvements. The unique characteristics of the various training programs potentially provide a basis from which to learn and to gain from one another.

Accurate Prediction of Tissue Viability at Postoperative Day 7 Using Only Two Intraoperative Subsecond Near-infrared Fluorescence Images

Background: The ability to predict the future viability of tissue while still in the operating room and able to intervene would have a major impact on patient outcome. Although several objective methods to evaluate tissue perfusion have been reported, none to date has sufficient accuracy. Methods: In eight Sprague-Dawley rats, reverse McFarlane dorsal skin flaps were created. Continuous near-infrared fluorescence angiography using indocyanine green was performed immediately after surgery, for a total of 30 minutes. These dynamic measurements were used to quantify indocyanine green biodistribution and clearance, and to develop a simple metric that accurately predicted tissue viability at postoperative day 7. The new metric was compared to previously described metrics. Results: Reproducible patterns of indocyanine green biodistribution and clearance from the flap permitted quantitative metrics to be developed for predicting flap viability at postoperative day 7. Previously described metrics, which set the boundary between healthy and necrotic tissue as either 17 or 25 percent of peak near-infrared fluorescence at 2 minutes after indocyanine green injection, underestimated the area of necrosis by 75 and 48 percent, respectively. Our data suggest that both the shape and area of clinical necrosis occurring at postoperative day 7 can be predicted intraoperatively, with the boundary defined as near-infrared fluorescence intensities of 40 to 55 percent of peak fluorescence measured at 5 minutes. Conclusion: Two 750-msec intraoperative near-infrared fluorescence images obtained at time 0 and at 5 minutes after injection of indocyanine green accurately predicted skin flap viability 7 days after surgery.

Oxygen-Sensing Paint-On Bandage: Calibration of a Novel Approach in Tissue Perfusion Assessment

Background: Knowledge of tissue oxygenation status is fundamental in the prevention of postoperative flap failure. Recently, the authors introduced a novel oxygen-sensing paint-on bandage that incorporated an oxygen-sensing porphyrin with a commercially available liquid bandage matrix. In this study, the authors extend validation of their oxygen-sensing bandage by comparing it to the use of near-infrared tissue oximetry in addition to Clark electrode measurements. Methods: The oxygen-sensing paint-on bandage was applied to the left hind limb in a rodent model. Simultaneously, a near-infrared imaging device and Clark electrode were attached to the right and left hind limbs, respectively. Tissue oxygenation was measured under normal, ischemic (aortic ligation), and reperfused conditions. Results: On average, the oxygen-sensing paint-on bandage measured a decrease in transdermal oxygenation from 85.2 mmHg to 64.1 mmHg upon aortic ligation. The oxygen-sensing dye restored at 81.2 mmHg after unclamping. Responses in both control groups demonstrated a similar trend. Physiologic changes from normal to ischemic and reperfused conditions were statistically significantly different in all three techniques (p < 0.001). Conclusions: The authors’ newly developed oxygen-sensing paint-on bandage exhibits a comparable trend in oxygenation recordings in a rat model similar to conventional oxygenation assessment techniques. This technique could potentially prove to be a valuable tool in the routine clinical management of flaps following free tissue transfer. Incorporating oxygen-sensing capabilities into a simple wound dressing material has the added benefit of providing both wound protection and constant wound oxygenation assessment.

Oncoplastic breast surgery: Achieving oncological and aesthetic outcomes

Oncoplastic reconstruction allows more patients to become candidates for breast‐conserving surgery (BCS). Oncologic resection of a breast lesion is combined with plastic surgical techniques to improve aesthetic results. Choosing the best oncoplastic method is essential to optimize outcomes, improve cosmesis, and minimize postoperative complications. The aim of this study is to present a treatment algorithm incorporating oncoplastic techniques based on diagnosis, tumor size, tumor location, and breast size and shape.

Prevalence of psychiatric comorbidities among women undergoing free tissue autologous breast reconstruction

Autologous breast reconstruction (BR) can be a stressful life event. Therefore, women undergoing mastectomy and autologous BR are required to have sufficient coping mechanisms. Although mental health problems are widespread, information regarding the prevalence of psychiatric diagnosis among these patients is scarce.

Regional and National Trends Over 20 Years in One-Stage vs Two-staged Implant Based Breast Reconstruction.

INTRODUCTION: Approximately 70% of patients undergoing reconstruction following mastectomy will receive implant-based breast reconstruction. However, the literature reports inconsistent breast reconstruction (BR) rates in terms of one-stage versus two-staged reconstruction protocols. The aim of this study was to assess national and regional trends in one-stage versus two-stage implant based breast reconstruction in the United States.