Background: COVID-19 significantly impacted the residency match process. Away rotations and in-person interviews were canceled in 2021, resulting in a geographic shift in integrated plastic surgery match results. Although several of these limitations were lifted during the 2022 cycle, the resulting geographic outcomes have yet to be described. This study aims to determine whether the changes seen during the previous cycle persisted despite loosened restrictions. Methods: Integrated plastic surgery match results and applicants' home institutions from the 2022 match cycle were determined using publicly available data. Geographic data from this cycle were then compared with pre-COVID-19 match cycles (2016-2020) and the COVID-19-affected 2021 match cycle. Results: Eighty percent (n = 68) of US integrated plastic surgery programs were included in this study. In 2022, 18.42% of applicants matched at their home institution compared with 25.12% in 2021. There was no significant difference in home, state, or regional match rates between 2022 and the five cycles preceding the pandemic (2016-2020). Combining these data to reflect the non-COVID-19-affected cycles (2016-2020 and 2022) and comparing to the COVID-19-affected cycle (2021), a significant difference in rates of home matches (P = 0.0395) was identified. Conclusions: A significant increase in home institution match rates was not noted during the 2022 cycle. This return to pre-COVID-19 rates is likely attributed to the loosening of restrictions and more opportunities for interaction between applicants and programs outside of their home institution.

Background: A patient's preoperative satisfaction with their breasts and baseline psychosocial, sexual, and physical well-being are important considerations when planning breast reconstruction. We sought to elucidate variances in preoperative responses among patients undergoing postmastectomy breast reconstruction. Methods: Preoperative BREAST-Q responses and demographic data, including race, generation, median household incomeinstitutional review board and body mass index (BMI) were collected from breast cancer patients scheduled for mastectomy. Associations between demographic group and survey response were analyzed by chi-square or independent t-tests. Results: In total, 646 of 826 patients identified had complete data and were included in the final analysis. Patients in BMI group 1 (16-24.9) were more likely to report feeling "very satisfied" with how they looked unclothed compared with patients in other BMI groups (P = 0.031). Conversely, patients in groups 3 and 4 (35+), reported lower satisfaction (P = 0.037) and felt less attractive without clothes (P = 0.034). Asian women were less likely to feel attractive (P = 0.007), and Black patients were less likely to feel of equal worth to other women (P < 0.001). Finally, patients were less likely to report confidence in social settings if they were Black (P < 0.001), Asian (P < 0.001), from the millennial generation (P = 0.017), or living in zip codes with median household income less than $55,000 (P = 0.042). Conclusions: Breast cancer patients' feelings toward their natural breasts vary widely between demographic groups. Understanding baseline psychosocial factors in this population is key to informing preoperative discussions and interpreting postoperative satisfaction.

Background: Patient decision regret can occur following elective healthcare decisions. The current era is focused on patient-reported outcomes, and decision regret is another metric by which surgeons can and should measure postoperative results. Patients who experience decision regret after elective procedures can often blame themselves, the surgeon, or the clinical practice, and this can lead to downstream psychological and economic consequences for all parties involved. Methods: A literature search was conducted on PubMed using the following search terms: (aesthetic surgery) AND (decision regret), (rhinoplasty) AND (decision regret), (face-lift) AND (decision regret), (abdominoplasty) AND (decision regret), (breast augmentation) AND (decision regret), (breast reconstruction) AND (decision regret), (FACE-Q) AND (rhinoplasty), (BREAST-Q) AND (breast augmentation). The following article types were included in the search: randomized controlled trials, meta-analysis, and systematic reviews. Results: After review of the literature, preoperative education, decisional tools, and postoperative complications were found to be the most important factors affecting decision regret after surgery. Conclusions: A better understanding of the factors associated with decision regret can help surgeons provide more effective preoperative counseling and prevent postoperative decision regret. Plastic surgeons can use these tools within a context of shared decision-making and ultimately increase patient satisfaction. Decision regret for plastic surgical procedures was mainly in the context of breast reconstruction. The differences in medical necessity create unique psychological challenges, emphasizing the need for more studies and a better understanding of the topic for other elective and cosmetic surgery procedures.

Background: COVID-19 had significant impact on the 2021 integrated plastic surgery match, most notably through cancellation of away rotations and virtual interviews. While previous studies have analyzed geographic outcomes of the match in prior years, the effects of COVID-19 have not been determined. This study aims to contribute 2021 match data to determine the effects of COVID-19 on the geographic distribution of the integrated plastic surgery match. Methods: Official match results for each program were populated by searching official program institutional websites and social media pages. Trainees' home medical institutions and current integrated plastic surgery residency programs were noted. Statistical analysis compared geographic distribution in COVID-19 affected (2021) and non-COVID-19 affected (2015-2020) match years. Results: Of 85 integrated plastic surgery programs, 80% (n = 68) of programs and 1,015 matched trainees were included in this study. The average percentage of institutional matches in COVID-19-affected match year was 25.12%, compared to 16.67% for non-COVID-19-affected match years (p = 0.0012). The odds ratio of matching at a home institution in 2021 compared to prior years was 1.68 (95% CI 1.11-2.53). Conclusions: Our study is consistent with previous studies that demonstrate strong match preferences for affiliated medical students but also adds that this trend may be amplified in the post-COVID-19 era. While multiple factors may be involved in geographic distributions of residency match outcomes, the results of this study suggest that COVID-19 restrictions on travel and exposure to outside programs may have contributed to an even higher percentage of matches within the same institution.

Background: Prognostic tools, such as risk calculators, improve the patient–physician informed decision-making process. These tools are limited for breast cancer patients when assessing surgical complication risk preoperatively. Objective: In this study, we aimed to assess predictors associated with acute postoperative complications for breast cancer patients and then develop a predictive model that calculates a complication probability using patient risk factors. Methods: We performed a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2017. Women diagnosed with ductal carcinoma in situ or invasive breast cancer who underwent either breast conservation or mastectomy procedures were included in this predictive modeling scheme. Four models were built using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. Model performance, accuracy and calibration measures during internal/external validation included area under the curve, Brier score, and Hosmer–Lemeshow statistic, respectively. Results: A total of 163,613 women met the inclusion criteria. The area under the curve for each model was as follows: overall, 0.70; infectious, 0.67; hematologic, 0.84; and internal organ, 0.74. Brier scores were all between 0.04 and 0.003. Model calibration using the Hosmer–Lemeshow statistic found all p-values to be > 0.05. Using model coefficients, individualized risk can be calculated on the web-based Breast Cancer Surgery Risk Calculator (BCSRc) platform (www.breastcalc.org). Conclusion: We developed an internally and externally validated risk calculator that estimates a breast cancer patient’s unique risk of acute complications following each surgical intervention. Preoperative use of the BCSRc can potentially help stratify patients with an increased complication risk and improve expectations during the decision-making process.

Background: Prior studies contrasting oncoplastic reduction (OCR) to traditional lumpectomy have validated oncoplastic reduction surgery with similar survival and oncological outcomes. The purpose of this study was to evaluate if there was a significant difference in the time to initiation of radiation therapy after OCR in comparison with the standard breast-conserving therapy (lumpectomy). Methods: The patients included were from a database of breast cancer patients who all underwent postoperative adjuvant radiation after either OCR or lumpectomy at a single institution between 2003 and 2020. Patients who experienced delays in radiation for nonsurgical reasons were excluded. Comparisons were made between the groups in the time to radiation and complication rates. Results: A total of 487 patients underwent breast-conserving therapy, with 220 having undergone OCR and 267 lumpectomy patients. There was no significant difference in days to radiation between patient cohorts (60.5 OCR, 56.2 lumpectomy, P = 0.059). There was a significant difference in the number of complications between OCR and lumpectomy patients (20.4% OCR, 2.2% lumpectomy, P < 0.001). However, of patients who had complications, there was no significant difference in the number of days to radiation (74.3 OCR, 69.3 lumpectomy, P = 0.732). Conclusions: Compared with lumpectomy, OCR was not associated with an increased time to radiation but was associated with higher complications. Statistical analysis did not reveal surgical technique or complications to be independent, significant predictors of increased time to radiation. Surgeons should be aware that although complications may remain higher in OCR, this does not necessarily translate to delays in radiation.

Background: Implant-based breast reconstruction can be accomplished in a variety of ways and can result in vastly different postoperative experiences for patients. The COVID-19 pandemic and recent trends have resulted in a shift toward outpatient management of these patients. Methods: A systematic review of PubMed and Embase databases was conducted. A total of 1328 articles were identified on initial search, and after several rounds of review, a total of four met inclusion and exclusion criteria. Manuscripts were included if postmastectomy alloplastic breast reconstruction was performed, and there was documentation of same-day discharge. This cohort of patients was compared with traditional, planned overnight admission cohorts found in the literature. Objective data compared between groups included preoperative patient factors and postoperative complication rates. Results: Four studies representing data on a total of 574 patients were included: 289 were same-day discharge and 285 were overnight admission. Patient characteristics of body mass index, radiation, smoking, and bilateral procedures were comparable. Tissue expanders were used more frequently than implants in both cohorts. The rate of overall complications was 33% for same-day discharge and 34% for overnight admission. Rates of major and minor complications, including infection, seroma, and hematoma, were similar. There was no increase in reoperations or readmissions reported in any of the studies. Conclusions: Same-day discharge after mastectomy with immediate alloplastic reconstruction is a safe approach to treatment in both the ambulatory and hospital setting. There are comparable rates of common complications such as infection, seroma, and hematoma, with no increase in readmission or reoperation.

The purpose of this summary is to outline the available research on the psychological factors associated with aesthetic surgery. Aesthetic procedures such as abdominoplasty, breast augmentation, face lift, and rhinoplasty are shown to have unique preoperative and postoperative psychological factors. Depression and anxiety may occur after aesthetic procedures with an increased incidence in patients with certain depression prone personality traits. The pre-existing psychology of patients is also an important contributing factor to consider when evaluating surgical candidates. Pre-existing mood disorders such as depression and anxiety are shown with higher incidence in individuals pursuing aesthetic procedures and can predispose such individuals to worsening mood symptoms postoperatively. This article aims to equip surgeons with a better understanding of the common psychological factors seen in the field of aesthetic surgery, so patients can be better supported throughout all parts of the surgical process.

The Goldilocks technique seeks to provide an alternative for patients with large breasts who are otherwise at risk of adverse complications in reconstructive techniques such as implant-based reconstruction or autologous free-tissue transfer. First coined in 2012, the “Goldilocks mastectomy” sought to bring the essence of the storybook character to practice, by allowing patients the opportunity to undergo a reconstructive technique that falls somewhere between the extremes of formal postmastectomy reconstruction and the flat appearance of mastectomy without reconstruction.1,2 This approach has been utilized in our practice as either an initial stage or the definitive form of reconstruction. As described in the operative techniques below, reconstruction is achieved by de-epithelializing and locally contouring autologous breast tissue to create a breast mound.

Background: Pre-pectoral prosthetic breast reconstruction following nipple-sparing mastectomy (NSM) has become a popular approach compared with the dual plane technique. Our objective was to determine if there was a difference in time to postoperative breast drain removal in direct-to-implant or tissue expander reconstruction following NSM when comparing pre-pectoral with dual plane technique. Methods: A total of 200 patients (335 breasts) received NSM followed by implant or expander reconstruction at our institution between the years 2009 and 2020. Direct-to-implant reconstruction had 113 pre-pectoral versus 67 dual plane, and tissue expander reconstruction had six pre-pectoral versus 149 dual plane. Our analysis included age at mastectomy, body mass index, history of preoperative breast radiation, and smoking history. Case complications included seroma or hematoma, breast or axillary infection requiring antibiotics or operative washout, device replacement due to extrusion or infection, skin necrosis, and capsular contracture. Statistical analysis was completed with Pearson chi-square test, Fisher exact test, and the two-sample T-test using IBM SPSS Statistics 24.0 (IBM Corp., Armonk, N.Y.). Results: The average time until breast drain removal in dual plane implant patients was significantly less than in pre-pectoral implant patients (9.42 versus 14.01 days). The average time until breast drain removal in dual plane expander patients was significantly less than in pre-pectoral expander patients (11.47 versus 20.30 days). Conclusion: In both implant and expander reconstruction following NSM, patients receiving dual plane device placement had a shorter postoperative time until breast drain removal when compared with patients receiving pre-pectoral device placement.